F L A T H E O F ColoreCtal CanCer Hematology ajho · ColoreCtal CanCer Adjuvant Chemotherapy in Older Adults With Colon Cancer Grant R. Williams, MD, and Hanna K. Sanoff, MD, MPH

T h e

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FFICIAL J

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AL O

F o f

ColoreCtal CanCer

Adjuvant Chemotherapy in Older Adults With Colon CancerGrant R. Williams, MD, and Hanna K. Sanoff, MD, MPH

Hematology

Novel Targets in Multiple MyelomaAjai Chari, MD

genomiCsClinical Applications and Limitations of Next-Generation SequencingReva Kakkar Basho, MD, Agda Karina Eterovic, PhD, and Funda Meric-Bernstam, MD

Breast CanCerThe PI3K Pathway as a Therapeutic Target in Breast CancerCynthia X. Ma, MD, PhDn

lung CanCerTo Treat or Not to Treat: When Is Adjuvant EGFR TKI Therapy Appropriate?Ramsey Asmar, MD, and Balazs Halmos, MD

A m e r i c a n

J o u r n a l

H e m a t o l o g y /

O n c o l o g y ®

a Peer-reviewed resource

for oncology education

ajho

www.AJHO.com issn 1939-6163 (print) issn 2334-0274 (online)

Volume 11 Number 3 3.15

gastrointestinal CanCer CME-certified enduring materials sponsored by Physicians’ Education Resource®, LLC

Angiogenesis Inhibitors for Gastrointestinal Cancers: Update From the 2015 Gastrointestinal Cancers Symposium

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Online CME ActivitiesQuickly find Online Activities that discuss issues that you are seeing in your practice today.

American Journal of Hematology/OncologyStay up to date with news and recent research with the official journal of PER®.

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Manage Your CMEKeep track of what CME activities you have participated in, request credit, and receive certificates of completion.

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Breast Cancer

DermatologicCancer

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Lung Cancer

Prostate Cancer

Targeted Therapies

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Table of Contents

ColoreCtal CanCer

Adjuvant Chemotherapy in Older Adults With Colon Cancer Grant R. Williams, MD, and Hanna K. Sanoff, MD, MPHIn this review, the authors present evidence for adjuvant chemotherapy in older adults with colorectal cancer, discuss helpful tools that can aid in adjuvant decision making, and present a suggested treat-ment approach to adjuvant chemotherapy in older adults with colorectal cancer.

Hematology

Novel Targets in Multiple MyelomaAjai Chari, MDDespite the availability of 5 classes of drugs for the treatment of multiple myeloma, the disease remains incurable in most cases, with patients eventually relapsing on each of these agents. In this review, the targets, mechanisms of action, safety, and efficacy of the novel agents, including the re-cently approved panobinostat, in multiple myeloma are considered.

genomiCs

Clinical Applications and Limitations of Next-Generation Sequencing Reva Kakkar Basho, MD, Agda Karina Eterovic, PhD, and Funda Meric-Bernstam, MDGrowing interest in personalized cancer therapy has led to numerous advances in the field of can-cer genomics. Next-generation sequencing has allowed for lower cost, higher-throughput genome sequencing. However, the vast number and types of genomic aberrations found in cancer means that interpretation of the data generated by next-generation sequencing requires substantial analytical complexity. The authors discuss the clinical applications of next-generation sequencing and the obsta-cles that must be overcome prior to widespread use in clinical decision making.

Breast CanCer

The PI3K Pathway as a Therapeutic Target in Breast Cancer Cynthia X. Ma, MD, PhDThe PI3K/Akt/mTOR signaling pathway is crucial to many aspects of cell growth and survival. The recognition of its importance in tumorigenesis and cancer progression has led to the development of a number of agents that target various components of this pathway as cancer therapeutics. Promising results with these agents have been observed in the treatment of advanced estrogen receptor–pos-itive (ER+) breast cancer, though there are ongoing efforts to investigate predictors of response and mechanisms of treatment resistance. lung CanCer

To Treat or Not to Treat: When Is Adjuvant EGFR TKI Therapy Appropriate?Ramsey Asmar, MD, and Balazs Halmos, MDThe use of EGFR TKI therapy in the adjuvant setting for nonmetastatic EGFR-mutated lung cancer remains under investigation, as conclusive data from earlier trials in unselected patients are lacking. Recent prospective trials suggest an improvement in disease-free survival with these agents; howev-er, an overall survival advantage is yet to be demonstrated.

5

11

17

23

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Table of Contents (continued)

Cme

CME-certified enduring materials sponsored by Physicians’ Education Resource®, LLCgastrointestinal CanCer

Angiogenesis Inhibitors for Gastrointestinal Cancers: Update From the 2015 Gastrointestinal Cancers SymposiumThe 2015 Gastrointestinal Cancers Symposium brought attendees up–to–date on advances in the treatment and diagnosis of gastrointestinal (GI) malignancies, with a focus on emerging agents and novel targeted agents. Several new antiangiogenic drugs are being evaluated in clinical trials for the treatment of several GI cancers, including colorectal cancer and hepatocellular carcinoma. This review presents highlights of some of the key presentations on novel antiangiogenic agents.

35

Patrick I. Borgen, MDChairman, Department of Surgery Maimonides Medical CenterDirector, Brooklyn Breast Cancer ProgramBrooklyn, NY

Julie R. Brahmer, MDAssociate Professor, Oncology Johns Hopkins University School of

MedicineSidney Kimmel Comprehensive Cancer

CenterBaltimore, MD

Myron S. Czuczman, MDProfessor of OncologyChief, Lymphoma/Myeloma ServiceDepartment of MedicineHead, Lymphoma Translational Research

LaboratoryDepartment of ImmunologyRoswell Park Cancer InstituteBuffalo, NY

David R. Gandara, MDProfessor of MedicineDirector, Thoracic Oncology ProgramSenior Advisor to the DirectorDivision of Hematology/OncologyUC Davis Comprehensive Cancer CenterSacramento, CA

Andre Goy, MD, MSChairman and Director Chief of LymphomaDirector, Clinical and Translational Cancer ResearchJohn Theurer Cancer Center at Hackensack University Medical CenterHackensack, NJ

John M. Kirkwood, MDUsher Professor of Medicine, Dermatology

and Translational ScienceDirector, Melanoma and Skin Cancer

ProgramUPMC Hillman Cancer CenterPittsburgh, PA

Michael Kolodziej, MD National Medical Director, Oncology Solutions

Office of the Chief Medical Officer, AetnaHartford, CT

Maurie Markman, MDPresident, Medicine & ScienceNational Director, Medical OncologyCancer Treatment Centers of America

John L. Marshall, MDChief, Hematology and Oncology Director, Otto J. Ruesch Center for the

Cure of Gastrointestinal CancersLombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashington, DC

Joyce A. O’Shaughnessy, MDCo-Director, Breast Cancer ResearchBaylor Charles A. Sammons Cancer

Center Texas Oncology The US Oncology NetworkDallas, TX

Daniel P. Petrylak, MDProfessor of Medicine (Medical Oncology) and of UrologyCo-Director, Signal Transduction Research

ProgramYale Cancer Center and Smilow Cancer

HospitalNew Haven, CT

Ramesh K. Ramanathan, MDProgram Lead, Gastrointestinal OncologySenior Associate AttendingMayo Clinic, ArizonaClinical Professor, Translational Genomics

Research Institute (TGEN)Phoenix, AZ

PER® Executive Board/AJHO Editorial Board

Editor-in-ChiefDebu Tripathy, MD

Professor and Chair Department of Breast Medical Oncology The University of Texas MD Anderson Cancer Center Houston, TX

Associate EditorMyron S. Czuczman, MD

Professor of OncologyChief, Lymphoma/Myeloma ServiceHead, Lymphoma Translational Research LaboratoryDepartment of ImmunologyRoswell Park Cancer InstituteBuffalo, NY

Managing EditorDevera Pine [email protected]

Editorial OfficesPhysicians’ Education Resource®, LLC666 Plainsboro Road, Ste. 356Plainsboro, NJ 08536(609) 378-3701

Medical DirectorMichael Perlmutter, MS, PharmD

eDitorial staFFFrom the Editor

The March issue of AJHO has a biological bent—which of course is an understandable trend as new drugs

entering into clinical practice are now more commonly biological agents. Moreover, the movement of

effective biological agents from advanced to adjuvant settings often (but not always) has the potential to

save more lives. In this vein, Drs Asmar and Halmos provide a perspective on the use of targeted agents

for early-stage lung cancer. Earlier trials were not using genomic assays to select patients, so the results of

ongoing trials—in particular, multifaceted trials such as the ALCHEMIST suite of trials—could change our

approaches significantly.

Adjuvant therapy for colon cancer still consists of cytotoxic agents, despite the effectiveness of angio-

genesis and EGFR-targeting drugs in the advanced setting. However, a significant proportion of patients

are elderly, and Drs Williams and Sanoff provide us with tools for decision support to factor age and oth-

er associated factors that predict toxicities and recurrence risk reduction, as well as alternative regimens to

optimize benefit/risk tradeoffs in this area.

Our hematological feature also illustrates the biological revolution as multiple myeloma is now

approached with both cytotoxic and biological drugs that are deployed in specific combinations based on

patient characteristics and treatment goals. Dr Chari provides a very useful summary of the current state

of the art and a preview of a new generation of targeted drugs under investigation.

Our pathway-based biology and targeted therapy review by Dr Ma focuses on PI3 kinase and down-

stream mTOR inhibitors in breast cancer. Recent results of PI3K inhibition are not producing the same

results seen with approved mTOR inhibitor therapy with everolimus, yet we cannot clearly explain this

with our current biological understanding of these pathways. The number of genomic-guided therapies

is rapidly growing, both in the clinical practice setting after FDA approval and in the clinical research

setting, where treatment decisions must be made rapidly.

Is next-generation sequencing that encompasses hundreds of genes the answer? Certainly, as the

cost drops and accuracy improves, we are very likely moving to high-throughput, broad-scale analytic

platforms that will require oncologists to become fluent with these technologies. Drs Basho, Eterovic,

and Meric-Bernstam provide a timely primer on the methods, applications, future potential, and current

limitations of next-generation sequencing.

Our CME article reviews updates from the ASCO GI symposium that revolve around one of the more

successfully targeted pathways—angiogenesis. Following the initial demonstration of bevacizumab of

improving survival in advanced colorectal cancer, two newer anti-angiogenic drugs have been approved be-

yond second line therapy with several others under investigation and showing various degrees of promise.

Chosen studies are highlighted and in this piece and provide a snapshot of the future landscape in this

area.

Debu Tripathy, MD Editor-in-Chief

Corporate oFFiCers Chairman and CEOMike Hennessy

Vice Chairman Jack Lepping

President Tighe Blazier

Chief Financial Officer Neil Glasser, CPA/CFE

Executive Vice President and General Manager John Maglione

Senior Vice President, Operations and Clinical Affairs Jeff Prescott, PharmD, RPh

Vice President, Human Resources Rich Weisman

Vice President, Executive Creative Director Jeff Brown

the content of this publication is for general information purposes only. the reader is encouraged to confirm the information presented with other sources. American Journal of Hematology/Oncology makes no representations or warranties of any kind about the completeness, accuracy, timeliness, reliability, or suitability of any of the information, including content or advertise-ments, contained in this publication and expressly disclaims liability for any errors and omissions that may be presented in this publication. American Journal of Hematology/Oncology re-serves the right to alter or correct any error or omission in the information it provides in this publication, without any obligations. American Journal of Hematology/Oncology further disclaims any and all liability for any direct, indirect, consequential, special, exemplary, or other damages arising from the use or misuse of any material or information presented in this publication. the views expressed in this publication are those of the authors and do not necessarily reflect the opinion or policy of American Journal of Hematology/Oncology.

VOL. 11, NO. 3 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 5

· colorectal cancer ·

Adjuvant Chemotherapy in Older Adults With Colon Cancer

Grant R. Williams, MD, and Hanna K. Sanoff, MD, MPH

Introduction Colorectal cancer (CRC) is the second leading cause of cancer death in the United States, with an estimated 136,000 new cases and over 50,000 deaths in 2014 alone.1 As with most cancers, CRC is predominately a disease of older adults. The median age of a CRC diagnosis is 68 years, and 59% of all cases of CRC are diagnosed in persons over the age of 65 years, with 35% old-er than 75 years.2 As the US population continues to age, the absolute number of cancer cases and the proportion of cancers occurring in the elderly (≥65 years) will both increase.3 Thus, pro-viding optimal care for older adults with CRC is a pressing issue.

A hallmark of aging is the gradual loss of physiologic reserve, with a resultant reduced ability to compensate when exposed to stressors such as infection, cancer, and chemotherapy.4,5 This loss of physiologic reserve is accompanied by a gradual decline in nor-mal organ function, such as reduced cardiac motility, glomerular

filtration rate, and hepatic volume.6-8 At the same time, older adults also have a shift in priorities and social support networks. Older adults are often less willing to initiate or continue treat-ments with severe adverse effects (AEs), and value their current time feeling well more than they value the potential for increased longevity.9,10 Thus, even when the likelihood of benefit may be the same, the AEs of adjuvant chemotherapy may be less ap-pealing to older patients. Adjuvant treatment decisions require a careful balance of changes in physiology and priorities, with decisions being thoughtfully individualized.

Since a 1990 National Institutes of Health consensus con-ference, adjuvant 5-fluoropyrimidine-based chemotherapy for node-positive CRC has become the standard of care in the United States.11 However, despite these recommendations, in-creasing age is significantly associated with lower likelihood of receiving any adjuvant chemotherapy.12 The use of any chemo-therapy drops off quickly with advancing age, with only 63% of those aged 75 to 79 years, 43% of those aged 80 to 84 years, and 14% of patients 85 years and older receiving adjuvant therapy.13 Whether this trend represents thoughtful and appropriate treat-ment on the part of patients and physicians based on comorbid disease and limited life expectancy or an inappropriate reflection of ageism is unclear.

Evidence for Adjuvant Therapy in Older AdultsIn light of the aforementioned age-related changes, it is very rea-sonable for patients and physicians to question whether adjuvant therapy is equally safe and effective in the elderly. However, be-cause only a small minority of clinical trial participants are over age 65 years, and even fewer over age 70, subset analyses by age within individual trials are underpowered.14 To overcome this challenge, multiple pooled analyses and meta-analyses have been performed. In 2001, a pooled analysis of 7 trials that randomly assigned participants to fluorouracil (5FU) with leucovorin (LV) versus observation in the adjuvant setting showed a similar ben-eficial treatment effect in older and younger patients.15 5FU/LV appears to be well tolerated in both the adjuvant and metastatic

Abstract

Colorectal cancer (CRC) is predominately a disease of

older adults, with the median age of diagnosis 68 years;

59% of all cases are diagnosed in persons age 65 years or

older. Although older patients have been underrepresent-

ed in clinical trials, pooled analysis suggests similar treat-

ment benefits with fluorouracil and leucovorin (5FU/LV)

for older patients compared with younger patients, while

the evidence of treatment benefit from oxaliplatin-con-

taining regimens is less compelling. Many helpful tools

that provide estimates of prognosis, risk of recurrence,

risk of severe toxicity with chemotherapy, and functional

age can aid clinical decisions. In this review, we present

the evidence for adjuvant chemotherapy in older adults,

discuss helpful tools that can aid in adjuvant decision

making, and present a suggested treatment approach to

adjuvant chemotherapy in older adults with CRC.

Key words: Colon cancer, adjuvant chemotherapy, elder-

ly, geriatric oncology, treatment-related decision making

6 www.ajho.com MARCH 2015


settings with similar grade 3 and 4 toxicity between younger and older patients with the exception of leukopenia without excess infection.15,16 These data have been confirmed in independent studies for both 5FU/LV and capecitabine.17-19

Based on the results of 3 adjuvant trials (MOSAIC,20 NS-ABP-C-07,21 and XELOXA22), oxaliplatin-based combinational chemotherapy is considered the standard of care for patients with stage III colon cancer, offering a 4% overall survival (OS) benefit over 5FU/LV at 6 years. However, the additional benefit of oxaliplatin in older patients appears to be attenuated. Subset analyses of MOSAIC and NSABP C-07 trials showed no signif-icant benefit in OS with the addition of oxaliplatin in patients age 70 or older (MOSAIC mortality hazard ratio [HR] = 1.10; 95% confidence interval [CI], 0.73-1.65; for NSABP-C-07, HR = 1.32; 95% CI, 1.03-1.70).20,21 In contrast, a subgroup analysis of XELOXA, a study that evaluated the use of oral capecitabine in combination with oxaliplatin versus bolus 5FU/LV, the benefits of disease-free survival (DFS) were maintained regardless of age, but no significant OS benefit was shown.22 In an analysis using the ACCENT23 database of 2575 patients age ≥70 years using oxaliplatin-based regimens versus 5FU/LV, although there was a trend toward improved time to recurrence in oxaliplatin-treated patients over age 70, there was no DFS or OS significant efficacy benefit. However, there was only a borderline significant interac-tion by age for OS (P = .05) and no significant interaction for DFS (P = .09), suggesting a lack of significant effect modification by age.23

Further evaluation of this in the MOSAIC subgroup saw the same trend toward prolongation of time to relapse; however, much shorter post-re-currence survival in oxaliplatin-treated patients may have mitigated the benefit of any delay in recurrence.20 The bene-fit of oxaliplatin seems to be reduced compared with younger patients in terms of DFS and OS, while maintain-ing time to recurrence. A recent large population-based analysis of patients treated outside the context of a clin-ical trial, presumably representing a broader range of patient population than clinical trial enrollees, showed a marginal improvement in survival with the addition of adjuvant oxaliplatin in patients age 75 and older.13 Overall, these findings suggest there is minimal or no survival benefit of additional ox-aliplatin to adjuvant 5FU/LV in adults age 70 or older with stage III CRC.24 In the management of patients with stage II CRC, the benefit of adjuvant

chemotherapy is small regardless of age, and oxaliplatin does not improve outcomes over 5FU/LV.20

Evaluating Older Adults With Cancer Given the potential for increased serious AEs and the long-term impacts associated with chemotherapy, the choice of whether to recommend adjuvant therapy to older adults should depend on an individual’s risk of recurrence, estimated life expectancy (without recurrence), and estimated risk of toxicity with treat-ment (see Table 1 for a list of useful online resources). These factors must all be considered in order to adequately weigh the risk/benefit of adjuvant treatment. Regardless of the objective measures of treatment benefit and toxicity, older patients may arrive at different personal trade-offs in terms of the benefits and risks of treatment, whether fit or frail.9 When discussing poten-tial treatment options, it is critical to consider a patient’s values and preferences to inform the decision-making process.

Due to the heterogeneous aging process, age alone is not an adequate measure of physiologic or functional age and is a poor determinant of cancer outcomes. Traditionally, tools such as the Karnofsky Performance Status (KPS) and Eastern Cooperative Oncology Group (ECOG) Performance Status have been used by oncologists to assess functional status, but these tools are limited to simple numeric scales that although helpful, do not accurately assess the function of older patients with cancer. Many tools have been developed to better evaluate a person’s functional age.

Table 1. Useful Resources for Management of Older Patients With Colorectal Cancer

Site Web address

Geriatric Assessment

International Society of Geriatric Oncology

www.siog.org

Portal of Geriatrics Online Education (POGOe)

www.pogoe.org

ASCO University www.university.asco.org/search/site/geriatrics

UNC Lineberger Geriatric Oncology Program

http://unclineberger.org/patientcare/ programs/geriatric/educational-materials-tools

Estimating Survival

ePrognosis www.eprognosis.org

Estimating Benefit

Adjuvant! Online www.adjuvantonline.org

Mayo Clinic Stage III Colon Cancer Calculator

http://www.mayoclinic.org/medical-profes-sionals/adjuvant-systemic-therapy-tools/

colon-cancer

Predicting Toxicity

Cancer and Aging Research Group

www.mycarg.org

Moffitt Cancer Center CRASH score

http://eforms.moffitt.org/crashScore.aspx

ASCO indicates American Society of Clinical Oncology; UNC, University of North Carolina.


AdjuvAnt ChemotherApy in older Adults with Colon CAnCer

The Comprehensive Geriatric Assessment (CGA) involves a careful review of a patient’s health status, including functional status, cognition, psychological state, nutritional status, social support, polypharmacy, and comorbid illnesses (see Table 2 for more details and suggested measures).25 The feasibility of an ab-breviated, primarily self-administered CGA has been shown in the oncology setting, in both community and academic outpa-tient clinics.26,27 CGA is able to detect impairments not typically identified in routine history or physical examinations, and can be predictive of survival, chemotherapy toxicity, postoperative mor-bidity, and mortality in older patients with cancer.28 The CGA is a useful tool in the assessment of a patient’s overall health status and potential frailty, a state of decreased physiologic reserve.4,29 Although there is no clear consensus or definition of frailty, a number of criteria can be used to identify vulnerable older adults, such as the presence of geriatric syndromes (such as falls or dementia) or dependence in activities of daily living.5 Given the high risk of adverse clinical outcomes for frail older adults,30 further research is under way to better identify this population. Current evidence supports evaluating elements of the CGA as a part of a routine evaluation of older adults with cancer.28

Estimating life expectancy (without recurrence) is a critical step in assessing the potential benefit of adjuvant treatment. Sev-eral tools are available to assist in life expectancy estimation for use within a variety of different populations.31 The vast majority of CRC recurrences occur within the first 3 years, and nearly all patients with recurrences will die within 5 years. However, in patients with significant competing comorbidities that limit overall survival, 6 months of adjuvant therapy for even a 15% improvement in survival may not be warranted.32 Also, the use of Web-based tools for assessing the benefit from adjuvant therapy can help quantify outcomes with and without adjuvant therapy. Tools such as Adjuvant! Online and the calculator derived from the ACCENT database can be useful aids in the discussion of the risk of tumor recurrence and potential benefits from adju-vant chemotherapy, but they need to be interpreted in the con-text of physiologic age.33,34

Although adjuvant chemotherapy is generally well tolerated in older adults, due to diversity in overall health and physical reserve inherent in older populations, the range of potential toxicities can vary greatly. In a seminal publication by Hurria et al,35 a chemotherapy toxicity prediction model was developed for use in older adults that incorporates features commonly known to increase risk of toxicity (age, creatinine clearance, baseline hemoglobin), as well as CGA measures such as hearing status, falls, and dependence on assistance with instrumental activities of daily living (IADL). For example, using this predictive tool, a fit 70-year-old male with no physical impairments would have an estimated 30% risk of grade 3-4 toxicity undergoing single-agent chemotherapy for CRC, whereas a similar 70-year-old male with fair hearing, a recent fall, and difficulty taking his own medica-

Table 2. Domains Typically Evaluated in a Compre-hensive Geriatric Assessment and Suggested Measures to Use

Domain Potential Measures

Function Status

Instrumental Activities of Daily Living (IADL)

Activities of Daily Living (ADL)

Timed Up and Go (TUG) or gait speed

Vision and hearing assessment

Falls assessment

ComorbidityNumber of comorbidities

Number of medications

CognitionMini-Cog, Mini-Mental State Exam (MMSE), or

Montreal Cognitive Assessment (MoCA)

NutritionUnintentional weight loss in past 6 months,

Mini Nutritional Assessment (MNA)

Body Composition

Body mass index (BMI), Lean body mass assessment

PsychologicalGeriatric Depression Scale (GDS), Patient

Health Questionnaire-9 (PHQ-9)

Social Support

Medical Outcomes Survey (MOS) social support survey

FIGURe 1. Comparison of Predicted Chemotherapy Toxicity for 4 Hypothetical Older Adults

fit 70 yo

% w

ith

seve

re t

oxic

ity

0

10

20

30

40

50

60

70

80

90

fit 80 yo unfit 70 yo unfit 80 yo

Comparison of the risk of severe toxicity (≥grade 3) related to chemotherapy of 4 hypothetical patients with colorectal cancer with varying age and fitness levels using chemotherapy toxicity calculator developed by Hurria et al.35 Fit patients have no physical impairments and no laboratory abnormalities, and unfit patients have fair hearing, a recent fall, and difficulty taking their own medications (IADL dependency), with no lab abnormalities.

YO indicates years old.



tions (IADL dependency) would be estimated to have a 72% risk of toxicity (Figure 1). Although the mortality risk from adjuvant chemotherapy itself is quite low, chemotherapy is associated with AEs that may potentiate or be potentiated by other comorbidi-ties, thus resulting in morbidity or worsened quality of life. In particular, oxaliplatin is associated with peripheral neuropathy that can be made potentially worse by pre-existing diabetes or lumbar stenosis, resulting in increased risk of falls and/or dis-ability.36

Adjuvant Treatment Approach in Older Adults With CRCThere is general agreement that fit, older adults who are active and without comorbidity and who have a life expectancy of at least 5 years should be offered adjuvant chemotherapy. Frail old-er adults with significant functional impairments and limited life expectancies are not suitable candidates for chemotherapy. In older adults who are neither fit nor frail, the decision-mak-

ing process is the most complex and requires a delicate balance of the risks and benefits informed by patient pref-erences. (Figure 2 provides an overview of the approach to adjuvant treatment decisions in older patients with CRC.)

In general, we recommend adjuvant chemotherapy in all fit older patients with stage III and many with stage II high-risk CRC. For fit patients with stage III disease with life expectancies substantially greater than 5 years—typi-cally patients in their late 60s and early 70s—we suggest considering an oxalipla-tin-based chemotherapy regimen, with the caveat that the absolute survival benefit is quite small. Given concern for relative 5FU/LV resistance in tumors deficient in mismatch repair enzymes, we use FOLFOX or omit chemotherapy altogether given good prognosis. Ox-aliplatin should be avoided in patients with pre-existing neuropathy, and it should be immediately stopped if sig-nificant toxicity emerges, given the un-certainty of the OS benefit of oxalipla-tin-based regimens in older adults. Due to the lack of compelling benefit of ox-aliplatin, we generally recommend using 5FU/LV or single-agent capecitabine. For 5FU, we recommend using the infu-sional modified de Gramont regimen. If an oxaliplatin-based regimen is chosen, we prefer the modified FOLFOX6 regi-

men, and frequently begin at 20% dose reduction and escalate subsequently if there are any concerns about tolerance. For pa-tients with issues with count recovery, which is more frequent with older patients, we omit 5FU bolus.37,38 In patients who are unable to tolerate an ambulatory infusion pump, capecitabine plus oxaliplatin (used in the XELOX trial) is also reasonable, but we typically use 825 mg/m2 to 850 mg/m2 twice daily rather than 1000 mg/m2.22

For patients who are deemed less fit or who have comorbid conditions that are likely to limit 5-year survival, as well as those with high-risk stage II disease that are mismatch repair enzyme proficient, we recommend single-agent fluoropyrimidine. Our preference in elderly patients is for infusional 5FU rather than capecitabine, both as a single agent and in combination, in light of capecitabine-based regimens being associated with greater tox-icity in older adults than infusional 5FU, at least in the meta-static setting where this has been tested.39 Eliminating the bolus

FIGURe 2. Overview of the Approach to Adjuvant Treatment Decisions in Older Adults With Colon Cancer

Consider 5FU or capecitabine

ModerateRisk

HighRisk

LowRisk

Consider FOLFOX or 5FU/capecitabine

Calculate Life Expectancy, EstimateFitness, and Elicit Patient Goals

Goalsconsistent

withaggressive Tx

Goals not consistent

withaggressive Tx

< 5 years > 5 years

Estimate risk of severe toxicity

Consider 5FU or capecitabine

No further Txnecessary

Frail FitNot fit nor

frail

Suggested adjuvant treatment algorithm for use in older adults with colorectal cancer based on life expectancy, overall health status, risk of toxicity, and patient goals.5FU indicates 5-fluorouracil; FOLFOX, 5-fluorouracil + oxaliplatin; Tx, treatment.


AdjuvAnt ChemotherApy in older Adults with Colon CAnCer

of 5FU from the infusion regimen may significantly mitigate hematologic toxicity.40 Although 6 months of therapy is the op-timal duration of adjuvant chemotherapy, there is evidence that 3 months of adjuvant chemotherapy may be adequate,41 so we feel comfortable discontinuing adjuvant therapy between 4 to 6 months if toxicity impairs quality of life.

ConclusionsIn general, we recommend adjuvant chemotherapy in all fit older patients with stage III and stage II high-risk CRC, and recom-mend carefully considering the risks and benefits of adjuvant therapy in nonfit and nonfrail older adults. We also believe that it is critical to elicit the values of our older patients to better understand their preferences with regard to how they balance the potential for life prolongation and risk of AEs. Older pa-tients receive similar benefits from 5FU-based chemotherapy as younger patients, but the incremental benefit from oxaliplatin is reduced. Treating older adults with CRC requires a careful-ly crafted individualized plan that balances an individual’s risk of recurrence, estimated life expectancy and risk of toxicity, and personal preferences.

Affiliations: Grant R. Williams, MD, and Hanna K. Sanoff, MD, MPH, are from the UNC Lineberger Comprehensive Can-cer Center and the Department of Medicine, Division of Hema-tology-Oncology, University of North Carolina at Chapel Hill.Disclosures: Dr Williams has no conflicts of interest to disclose. Dr Sanoff has received grants from Bayer and Novartis and con-sulting fees from Amgen. Address correspondence to: Grant R. Williams, MD, University of North Carolina at Chapel Hill, Physician’s Office Building, 170 Manning Dr, 3rd Floor, Campus Box 7305, Chapel Hill, NC 27599-7305. Phone: 919-627-3221; fax: 919-966-6735; email: [email protected].

REFEREnCEs1. American Cancer Society. Cancer Facts & Figures 2014. Atlanta, GA: American Cancer Society; 2014.2. Surveillance Epidemiology and End Results (SEER) program. http://seer.cancer.gov/faststats/index.php. Accessed February 23, 2015.3. Smith BD, Smith GL, Hurria A, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27(17):2758-2765.4. Ferrucci L, Guralnik JM, Cavazzini C, et al. The frailty syndrome: a critical issue in geriatric oncology. Crit Rev Oncol Hematol. 2003;46(2):127-137.5. Walston J, Hadley EC, Ferrucci L, et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics

Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc. 2006;54(6):991-1001.6. Boss GR, Seegmiller JE. Age-related physiological changes and their clinical significance. Western J Med. 1981;135(6):434-440.7. Sawhney R, Sehl M, Naeim A. Physiologic aspects of aging: impact on cancer management and decision making, part I. Cancer J. 2005;11(6):449-460.8. Sehl M, Sawhney R, Naeim A. Physiologic aspects of aging: impact on cancer management and decision making, part II. Cancer J. 2005;11(6):461-473.9. Yellen SB, Cella DF, Leslie WT. Age and clinical decision making in oncology patients. J Natl Cancer Inst. 1994;86(23):1766-1770.10. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066.11. NIH consensus conference. Adjuvant therapy for patients with colon and rectal cancer. JAMA. 1990;264(11):1444-1450.12. Cronin DP, Harlan LC, Potosky AL, et al. Patterns of care for adjuvant therapy in a random population-based sample of patients diagnosed with colorectal cancer. Am J Gastroenterol. 2006;101(10):2308-2318.13. Sanoff HK, Carpenter WR, Sturmer T, et al. Effect of adjuvant chemotherapy on survival of patients with stage III colon cancer diagnosed after age 75 years. J Clin Oncol. 2012;30(21):2624-2634.14. Lewis JH, Kilgore ML, Goldman DP, et al. Participation of patients 65 years of age or older in cancer clinical trials. J Clin Oncol. 2003;21(7):1383-1389.15. Sargent DJ, Goldberg RM, Jacobson SD, et al. A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients. N Engl J Med. 2001;345(15):1091-1097.16. D’Andre S, Sargent DJ, Cha SS, et al. 5-fluorouracil-based chemotherapy for advanced colorectal cancer in elderly patients: a North Central Cancer Treatment Group study. Clin Colorectal Canc. 2005;4(5):325-331.17. Fata F, Mirza A, Craig G, et al. Efficacy and toxicity of adjuvant chemotherapy in elderly patients with colon carcinoma: a 10-year experience of the Geisinger Medical Center. Cancer. 2002;94(7):1931-1938.18. Gill S, Loprinzi CL, Sargent DJ, et al. Pooled analysis of fluorouracil-based adjuvant therapy for stage II and III colon cancer: who benefits and by how much? J Clin Oncol. 2004;22(10):1797-1806.19. Twelves C, Scheithauer W, McKendrick J, et al. Capecitabine versus 5-fluorouracil/folinic acid as adjuvant therapy for stage III colon cancer: final results from the X-ACT trial with analysis by age and preliminary evidence of a pharmacodynamic marker of efficacy. Ann Oncol. 2012;23(5):1190-1197.20. Tournigand C, Andre T, Bonnetain F, et al. Adjuvant therapy with fluorouracil and oxaliplatin in stage II and elderly patients



(between ages 70 and 75 years) with colon cancer: subgroup analyses of the Multicenter International Study of Oxaliplatin, Fluorouracil, and Leucovorin in the Adjuvant Treatment of Colon Cancer trial. J Clin Oncol. 2012;30(27):3353-3360.21. Yothers G, O’Connell MJ, Allegra CJ, et al. Oxaliplatin as adjuvant therapy for colon cancer: updated results of NSABP C-07 trial, including survival and subset analyses. J Clin Oncol. 2011;29(28):3768-3774.22. Haller DG, Tabernero J, Maroun J, et al. Capecitabine plus oxaliplatin compared with fluorouracil and folinic acid as adjuvant therapy for stage III colon cancer. J Clin Oncol. 2011;29(11):1465-1471.23. McCleary NJ, Meyerhardt JA, Green E, et al. Impact of age on the efficacy of newer adjuvant therapies in patients with stage II/III colon cancer: findings from the ACCENT database. J Clin Oncol. 2013;31(20):2600-2606.24. Papamichael D, Audisio RA, Glimelius B, et al. Treatment of colorectal cancer in older patients: International Society of Geriatric Oncology (SIOG) consensus recommendations 2013 [published online July 11, 2014]. Ann Oncol. pii:mdu253. 25. Hurria A. Geriatric assessment in oncology practice. J Am Geriatr Soc. 2009(57, suppl 2):S246-249.26. Hurria A, Cirrincione CT, Muss HB, et al. Implementing a geriatric assessment in cooperative group clinical cancer trials: CALGB 360401. J Clin Oncol. 2011;29(10):1290-1296.27. Williams GR, Deal AM, Jolly TA, et al. Feasibility of geriatric assessment in community oncology clinics. J Geriatr Oncol. 2014;5(3):245-251.28. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol. 2014. doi:10.1200/JCO.2013.54.8347.29. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156.30. Bandeen-Roche K, Xue QL, Ferrucci L, et al. Phenotype of frailty: characterization in the women’s health and aging studies. J Gerontol A Biol Sci Med Sci. 2006;61(3):262-266.31. Yourman LC, Lee SJ, Schonberg MA, et al. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.32. Sargent DJ, Wieand HS, Haller DG, et al. Disease-free survival versus overall survival as a primary end point for adjuvant colon cancer studies: individual patient data from 20,898 patients on 18 randomized trials. J Clin Oncol. 2005;23(34):8664-8670.33. Gill S, Loprinzi C, Kennecke H, et al. Prognostic Web-based models for stage II and III colon cancer: a population- and clinical trials-based validation of numeracy and Adjuvant! Online. Cancer. 2011;117(18):4155-4165.34. Renfro LA, Grothey A, Xue Y, et al. ACCENT-based Web calculators to predict recurrence and overall survival in stage III colon cancer. J Natl Cancer Inst. 2014;106(12).

35. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol. 2011;29(25):3457-3465.36. Andre T, Boni C, Mounedji-Boudiaf L, et al. Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. New Engl J Med. 2004;350(23):2343-2351.37. Hochster HS, Grothey A, Hart L, et al. Improved time to treatment failure with an intermittent oxaliplatin strategy: results of CONcePT. Ann Oncol. 2014;25(6):1172-1178.38. Hochster HS, Hart LL, Ramanathan RK, et al. Safety and efficacy of oxaliplatin and fluoropyrimidine regimens with or without bevacizumab as first-line treatment of metastatic colorectal cancer: results of the TREE study. J Clin Oncol. 2008;26(21):3523-3529.39. Seymour MT, Thompson LC, Wasan HS, et al. Chemotherapy options in elderly and frail patients with metastatic colorectal cancer (MRC FOCUS2): an open-label, randomised factorial trial. Lancet. 2011;377(9779):1749-1759.40. Sanoff HK, Bleiberg H, Goldberg RM. Managing older patients with colorectal cancer. J Clin Oncol. 2007;25(14):1891-1897.41. Chau I, Norman AR, Cunningham D, et al. A randomised comparison between 6 months of bolus fluorouracil/leucovorin and 12 weeks of protracted venous infusion fluorouracil as adjuvant treatment in colorectal cancer. Ann Oncol. 2005;16(4):549-557.


· Hematology ·

Novel Targets in Multiple Myeloma

Ajai Chari, MD

Although there currently are 5 classes of drugs available for the treatment of multiple myeloma (MM; Table 1), the disease re-mains incurable in most cases, with patients eventually relaps-ing on each of these agents. The benchmark for drug approval based on 2 recent agents approved by the FDA (carfilzomib and pomalidomide) in the relapsed/refractory space is likely to be an overall response rate (ORR) of approximately 25% to 30% and progression-free survival (PFS) of approximately 4 months.1,2 The goal of this review is to discuss the targets, mechanisms of action (MOA), safety, and efficacy of the novel agents in MM that are currently thought to have the best chance of meeting these benchmarks.

Targets of IMiDsOf note, there also have been developments in our understand-ing of the targets of immunomodulatory drugs (IMiDs). Until recently, it has been unclear how these oral medications achieve antimyeloma benefits without significant toxicity at the site of drug absorption in the gut or other off-target organ toxicities. Recently, cereblon, a member of the E3 ubiquitin ligase family, was identified as the likely mediator of teratogenicity of IMiDs.Cereblon also implicates IMiDs in the dysregulation of the ubi- quitination process that targets proteins for proteasomal degra-dation.3 Malignant plasma cells, by virtue of being antibody/pro-tein factories, have been demonstrated to be extremely vulnera-ble to such dysregulation by the proteasome inhibitor (PI) drug class. Moreover, additional work suggests that the immunologic changes associated with IMiDs may be due to Aiolos and Ikaros, which are not only substrates of cereblon, but also transcription factors involved in interleukin 2–mediated T cell activation.4 A better understanding of the MOA of these agents in MM will be essential to overcoming drug resistance and to developing the next generation of IMiDs and PIs.

Fortunately there are also several promising new drug targets in MM (Table 2). To date, there has been no rituximab—that is, a monoclonal antibody (mAb) with single-agent activity in MM. CD38 is a transmembrane glycoprotein and ectoenzyme with high receptor density on MM cells.5 The CD38 antibod-ies daratumumab and SAR650982 are both humanized IgG1 mAbs with multiple MOA, including antibody-dependent cel-lular cytotoxicity (ADCC) and phagocytosis, complement-depen-dent cytotoxicity, direct apoptosis induction, and inhibition of CD38 enzymatic activity.6 Other than manageable infusional

Abstract

Despite the availability of 5 classes of drugs for the treat-

ment of multiple myeloma (MM), the disease remains

incurable in most cases, with patients eventually relaps-

ing on each of these agents. The benchmark for drug ap-

proval is likely to be an overall response rate (ORR) of

approximately 25% to 30% and progression-free survival

(PFS) of approximately 4 months. This article reviews the

targets, mechanisms of action (MOA), safety, and effica-

cy of the novel agents in MM that are currently thought

to have the best chance of meeting these benchmarks,

including the recently approved panobinostat. After a

brief update on putative MOA of immunomodulato-

ry (IMiDs) drugs, the following monoclonal antibodies

(mAbs) are discussed: the CD38 antibodies daratumum-

ab and SAR650982, the CS1 antibody elotuzumab, and

indatuximab ravtansine—a CD138 antibody conjugated

to maytansinoid. Non-mAbs discussed include inhibitors

of histone deacetylases, kinesin spindle protein, AKT3,

PIM kinase, and nuclear transport (XPO1).

Key words: Multiple myeloma, prednisone, dexameth-

asone, thalidomide, lenalidomide, pomalidomide,

bortezomib, carfilzomib, panobinostat, melphalan, cy-

clophosphamide, doxorubicin, DCEP/D-PACE, BCNU,

bendamustine

Practical Application

• Areviewofcurrentlyapproveddrugclassesforthetreatmentofmultiplemyeloma(MM)

• AreviewofnovelagentsunderdevelopmentforthetreatmentofMM,includingtheir:

-mechanismsofaction -safetyandtoxicityprofiles -efficacy


· Hematology ·

toxicities expected with mAbs, both agents are well tolerated. In small phase 2 studies, both agents have shown single-agent activity with an overall response rate (ORR) in the range of 30% to 35% and 60% to 70% when combined with lenalidomide (Table 3).7-10 Daratumumab received breakthrough designation in May 2013 for patients with MM who have received more than 3 lines of therapy or are IMiD- and PI-refractory. Once these agents are approved, it is expected that they quickly will be moved throughout the disease spectrum, and also, based on preliminary data from combination studies demonstrating non-overlapping toxicity and improved efficacy, eventually be approved for ad-ministration with many of the agents in Table 1.

Another mAb that has already entered phase 3 studies in MM is elotuzumab, which is a humanized IgG1 mAb that targets cell surface 1 (CS1), a member of the SLAM family, which is uniformly and highly expressed in more than 95% of patients with primary MM, but not on stem cells or other

normal tissues. The MOA appears to be ADCC-mediated by natural killer (NK) cells.11 Although elotuzumab has no significant sin-gle-agent activity, it has an excellent safety pro-file when given weekly for two 28-day cycles, and thereafter on days 1 and 15 in combina-tion with a lenalidomide and dexamethasone backbone. Grades 3 and 4 toxicities are primar-ily hematologic and range from 10% to 15%, likely due to lenalidomide, except perhaps for lymphopenia. However, there was no signifi-cant increase in infections. In a phase 2 study of 36 lenalidomide-naïve patients who received elotuzumab 10 mg/kg in combination with lenalidomide and dexamethasone, the ORR was 92% and PFS was 33 months,12 relative to historic controls of lenalidomide-dexametha-sone with an ORR of approximately 60% and

PFS of 11 months.13,14 Elotuzumab received breakthrough desig-nation by the FDA in May 2014 for more than 1 line of therapy given with lenalidomide-dexamethasone.

The last mAb with an encouraging signal in MM is indatux-imab ravtansine (formerly known as BT062), an anti-CD138 chi-merized monoclonal IgG4 linked to the microtubule inhibitor maytansinoid (DM4). CD138 is primarily expressed on MM cells and also on epithelial cells, albeit to a lesser extent. Once the mAb binds to CD38, internalization and lyosomal processing of the linker releases the cytotoxic DM4 metabolites that result in apoptosis due to inhibition of tubulin polymerization.15 A phase 1 dose-escalation study showed dose-limiting toxicities of elevated gamma-glutamyltransferase, mucositis, and hand-foot syndrome. Serious adverse events also included gastrointestinal bleeding and corneal damage. Although monotherapy produced stable disease or better in 50% of patients, the ORR was only 4%, and therefore it is unlikely to move forward as a single agent.16 When combined with lenalidomide-dexamethasone, 100% of patients had stable disease or better, including an ORR of 75% in a small number of lenalidomide-refractory patients.17

Although MM cells are initially susceptible to PI therapy, the aggresome pathway is also responsible for the destruction of misfolded proteins. Dual pathway inhibition has demonstrated preclinical synergy.18 Two oral pan-histone deacetylase inhibitors (HDACs) have completed large phase 3 studies. The VANTAGE study19 comparing bortezomib and dexamethasone with either vorinostat or placebo showed only a disappointing 0.8-month improvement in PFS over the control arm. More recently, the PANORAMA 1 study20 with bortezomib (intravenous) and dexamethasone with either panobinostat or placebo showed a 3.9-month improvement in PFS and an improvement in com-plete response (CR) rates from 15.7% to 27.6%. However, the rates of grade 3 or 4 diarrhea increased from 8% to 25%. Most

Table 2. Novel Targets in Multiple Myeloma

Target agent

CS1 elotuzumab

CD38 daratumumabSAR650982

CD138 indatuximab ravtansine (BT-062 + maytansinoid)

HDAC6 ricolinostat

KSP1 filanesib

AKT3 afuresertib

XPO1 selinexor

PIMkinase LGH447

Table 1. Currently Available Anti-Myeloma Therapies

BCNU indicates bis-chloroethylnitrosourea (carmustine); DCEP, dexamethasone + continuous IV infusion of cyclophosphamide + etoposide + cisplatin; D-PACE, dexa-methasone + continuous IV infusion of cisplatin + doxorubicin + cyclophospha-mide + etoposide; HDAC, histone deacetylase; IMiDs, immunomodulatory drugs.

Steroids IMiDs Proteasome Inhibitors

HDaC Inhibitors

ConventionalChemotherapy

Prednisone Thalidomide Bortezomib Panobinostat Melphalan

Dexamethasone Lenalidomide Carfilzomib Cyclophosphamide

Pomalidomide Doxorubicin

DCEP/D-PACE

BCNU

Bendamustine


Novel TargeTs iN MulTiple MyeloMa

likely, the diarrhea is attributable to the combination of pano-binostat with intravenous bortezomib, as these rates of diarrhea have not been seen when panobinostat is combined with subcu-taneous bortezomib, carfilzomib, or lenalidomide.21-23 Moreover, PANORAMA 224 demonstrated that the addition of panobinostat to bortezomib in bortezomib-refracto-ry patients resulted in a response rate (RR) of 34.5% and PFS of 5.4 months. Panobinostat was approved by the FDA on February 23, 2015, in combination with bortezomib and dexamethasone in patients who have received at least 2 prior regimens (including bortezomib and an IMiD). Ricolinostat, an oral specific inhibitor of HDAC6, a key component of the aggresome pathway, is also under investigation (Table 4).

There are additional non-mAb novel agents with single-agent activity in development (Table 5). Filane-sib is a highly selective allosteric inhibitor of kinesin spindle protein (KSP), which is a microtubule motor protein. KSP inhibition prevents formation of a bipolar spindle, leading to apoptosis particularly in Mcl-1–de-pendent MM cells. As a single agent, the main toxicity is neutropenia, which is manageable with prophylactic granulocyte-colony stimulating factor (GCSF). As a sin-gle agent, the ORR is 16% and the median PFS is 3.7 months (n=32), which is comparable to the 15% and 3.4 months with the addition of dexamethasone to fila-nesib (n=55), albeit this was in a much more heavily pretreated, IMiD- and PI-refractory population. Of par-ticular interest though, is the potential biomarker alpha 1-acid glycoprotein (AAG), an acute-phase protein used to monitor inflammatory conditions. AAG binds to

filanesib such that high AAG concentrations result in increased IC50 for filanesib in vitro. Lower AAG levels seem to correlate with clinical outcomes, as such patients had an ORR without dexamethasone of 24% and a median PFS of 5.1 months.25 Al-

Table 3. Summary of Efficacy of Monoclonal Antibodies(at recommended phase 2/phase 3 dosages)

Daratumumab granted FDA breakthrough designation May 2013 for >3 lines of therapy or PI- and IMiD-refractory disease.Elotuzumab granted FDA breakthrough designation May 2014 for >1 line of therapy given with Len-Dex.

Bor indicates bortezomib; Car, carfilzomib; Dex, dexamethasone; DOR, duration of response; IMiD, immunomodulatory drug; Mos, months;Len, lenalidomide; NR, not reported; PFS, progression-free survival; OS, overall survival; PI, proteasome inhibitor; Refr, refractory.

Treatment N eligibility (% Refractory)

Response Rate PFS(mos)

DOR (mos)

OS (mos)

ElotuzumabLenDex12 36 0%, Len sensitivity required 92% 33 17.8 NR

Daratumumab7 20 50%/75%/38%(% Refr: Bor/Len/Bor+Len)

35% (n = 20) NR NR NR

SAR6509848 13 69% Car+Pom exposed 30.8% NR 5+ NR

DaratumumabLenDex9 30 6.7% Len Refr 87% NR NR NR

SAR650984LenDex10 24 80% Len/20% Pom~60% Bor/~50% Car

63% (48% in Len Refr,n = 25)

5.8 NR NR

BT062LenDex17 21 100% Bor/87% Len 73% (75% in Len Refr, n = 8) NR NR NR

Table 4. Summary of Combination Therapy With Histone Deacetylase Inhibitors

Bor indicates bortezomib; CBR, clinical benefit rate; Dex, dexamethasone; DOR, duration of response; IMiD, immunomodulatory drug; Len, lenalid-omide; Mos, months; ORR, overall response rate; OS, overall survival; PI, proteasome inhibitor; PFS, progression-free survival; Refr, refractory.

Regimen Phase (N) Outcomes

Panobinostatorplace-bo+BorDex20

3 (768) ORR: 60.7% vs 54.6% (P = .09)PFS: 12.0 vs 8.1 mos (P < .0001) OS: 33.6 vs 30.4 mos (P = .26)

Panobinostat+BorDex24

2 (55 Bor refr)

ORR 34.5%; CBR 52.7%

Panobinostat+LenDex23

2(19)

ORR: 31%; CBR: 52 %N = 14; Len Refr : ORR: 21%CBR: 42%

Panobinostat+Carfilzomib22

1/2(26)

ORR: 46%; CBR: 52 %Bor Refr: ORR: 44%; n = 26

Vorinostatorplacebo+Bor19(noDex)

3(637)

ORR: 54% vs 41% (P < .0001)PFS: 7.6 vs 6.8 mos (P < .01); OS: no difference

Ricolinostat±BorDex32

1 (20) ORR: 25%; CBR: 60%

Ricolinostat+LenDex33

1 (22) ORR: 64%; CBR: 100%


· Hematology ·

though linking drug approval to a novel biomarker is not an easy path forward, to date, there are no biomarkers predictive of re-sponse in MM, and KSP inhibition is a novel MOA in MM. Filanesib was granted orphan drug approval by the FDA in May 2014.

The phosphatidylinositide 3-kinase (PI3K)-AKT-mammalian target of rapamycin (mTOR) signaling pathway is activated in MM, and preclinically, inhibition of this pathway leads to apoptosis.26 The oral AKT3 inhibitor afuresertib showed a sin-gle-agent RR of 8.8%.27 PIM kinases also promote tumor cell proliferation and survival, and are overexpressed in hematologic malignancies.28 The pan-PIM kinase inhibitor LGH 447 recently demonstrated a monotherapy RR of 10.5%.29 While the single agent responses for afuresertib and LGH 447 are modest, better patient selection or combination strategies may be more effica-cious.

Finally, the nuclear protein exportin 1 (XP01) is a promising target in oncology. Preclinically, inhibition of XPO1 induced MM cytotoxicity and impaired osteoclastogenesis.30 Although the data are very preliminary, the nuclear transport inhibitor known as selinexor (KPT-330) has already demonstrated activity. In 8 patients with MM who were refractory to all drug classes and were treated with selinexor and dexamethasone, the re-sponse rate was 50%.31

Although PIs and IMiDs have yielded significant improve-ment in MM outcomes, the currently available classes of drugs can take us only so far, as evidenced by the modest ORR and PFS of recently approved agents. Further improvements will require a better understanding of myelomagenesis, a better understanding of the mechanisms of resistance to current agents, biologically guided/risk-adapted therapy, and finally, the development of

agents with novel targets. Fortunately, as reviewed here, there are many such promising agents.

Affiliation: Ajai Chari, MD, is from the Mount Sinai School of Medicine, New York, NY. Disclosure: Dr Chari has served as a consultant or on a paid ad-visory board for Array Biopharma, Celegene, Millennium/Take-da, and Novartis and has received grants from Array Biopharma, Celgene, Millennium/Takeda, Novartis, Onyx, GlaxoSmith-Kline, and Pharmacyclics.Address correspondence to: Ajai Chari, MD, 1 Gustave Levy Place, Box 1185, New York, NY 10029. Phone: 212-241-7873; fax: 212-241-3908; email: [email protected].

RefeRences1. Siegel DS, Martin T, Wang M, et al. A phase 2 study of sin-gle-agent carfilzomib (PX-171-003-A1) in patients with relapsed and refractory multiple myeloma. Blood. 2012;120(14):2817-2825.2. San Miguel J, Weisel K, Moreau P, et al. Pomalidomide plus low-dose dexamethasone versus high-dose dexamethasone alone for patients with relapsed and refractory multiple myeloma (MM-003): a randomised, open-label, phase 3 trial. Lancet Oncol. 2013;14(11):1055-1066.3. Ito T, Ando H, Suzuki T, et al. Identification of a primary tar-get of thalidomide teratogenicity. Science. 2010;327(5971):1345-1350.4. Gandhi AK, Kang J, Havens CG, et al. Immunomodulatory agents lenalidomide and pomalidomide co-stimulate T cells by inducing degradation of T cell repressors Ikaros and Aiolos via

Table 5. Summary of Non-Monoclonal Antibody Novel Agents With Single-Agent Activity

Filanesib granted orphan drug approval by FDA May 2014.

AAG indicates alpha 1-acid glycoprotein; Bor, bortezomib; CBR, clinical benefit rate; Dex, dexamethasone; DOR, duration of response; Exp, exposed; IMiD, immunomodulatory drug; Len, lenalidomide; Mos, months; ORR, overall response rate; OS, overall survival; PI, proteasome inhibitor; PFS, progression-free survival; Refr, refractory; Sens, sensitive.

Treatment N eligibility ORR PFS (mos) DOR (mos) OS

IxazomibDex 33 88% Len Exp; Bor Sens 34% 12.4 NR 96% @ 6 mos

FilanesibinlowAAG25

32 21

75% IMiD Refr53% PI Refr

16%24%

3.75.3

8.68.6

19 mos23.3 mos

FilanesibDexinlowAAG25

55 36

100% IMiD Refr98% PI Refr

15%19%

3.45.1

5.15.1

10.5 mos10.8 mos

Afuresertib27 34 97% IMiD Exp;88% PI Exp

8.8% NR NR NR

SelinexorDex32 8 Refrtoallclasses 50% NR NR NR

LGH44729 59 NR 10.5% NR 5.8 NR


Novel TargeTs iN MulTiple MyeloMa

modulation of the E3 ubiquitin ligase complex CRL4(CRBN). Br J Haematol. 2014;164(6):811-821.5. Lin P, Owens R, Tricot G, Wilson CS. Flow cytometric im-munophenotypic analysis of 306 cases of multiple myeloma. Am J Clin Pathol. 2004;121(4):482-488.6. Deckert J, Wetzel MC, Bartle LM, et al. SAR650984, a novel humanized CD38-targeting antibody, demonstrates potent anti-tumor activity in models of multiple myeloma and other CD38+ hematologic malignancies. Clin Cancer Res. 2014;20(17):4574-4583.7. Lokhorst HM, Laubach J, Nahi H,et al. Dose-dependent effi-cacy of daratumumab (DARA) as monotherapy in patients with relapsed or refractory multiple myeloma (RR MM). Presented at: the 2014 American Society of Oncology Annual Meeting; May 30-June 3, 2014; Chicago, IL. Abstract 8513. 8. Martin TG, Hsu K, Strickland SA, et al. A phase I trial of SAR650984, a CD38 monoclonal antibody, in relapsed or re-fractory multiple myeloma. Presented at the 2014 American Soci-ety of Clinical Oncology Annual Meeting; May 30-June 3, 2014; Chicago, IL. Abstract 8532.9. Plesner T, Arkenau H-T, Lokhorst HM, et al. Safety and ef-ficacy of daratumumab with lenalidomide and dexamethasone in relapsed or relapsed, refractory multiple myeloma. Presented at: the 2014 American Society of Hematology Annual Meeting; December 6-9, 2014; San Francisco, CA. Abstract 84.10. Martin TG, Baz R, Benson Jr DM, et al. A phase Ib dose es-calation trial of SAR650984 (anti-CD-38 mAb) in combination with lenalidomide and dexamethasone in relapsed/refractory multiple myeloma. Presented at: the 2014 American Society of Hematology Annual Meeting; December 6-9, 2014; San Francis-co, CA. Abstract 83 .11. Hsi ED, Steinle R, Balasa B, et al. CS1, a potential new ther-apeutic antibody target for the treatment of multiple myeloma. Clin Cancer Res. 2008;14(9):2775-2784.12. Richardson PG, Jagannath S, Moreau P, et al. A phase 2 study of elotuzumab (elo) in combination with lenalidomide and low-dose dexamethasone (Ld) in patients (pts) with relapsed/refrac-tory multiple myeloma (R/R MM): updated results. Presented at: the 2012 American Society of Hematology Annual Meeting; December 8-11, 2012; Atlanta, GA. Abstract 202.13. Weber DM, Chen C, Niesvizky R, et al. Lenalidomide plus dexamethasone for relapsed multiple myeloma in North Ameri-ca. N Engl J Med. 2007;357(21):2133-2142.14. Dimopoulos M, Spencer A, Attal M, et al. Lenalidomide plus dexamethasone for relapsed or refractory multiple myeloma. N Engl J Med. 2007;357(21):2123-2132.15. Ikeda H, Hideshima T, Fulciniti M, et al. The monoclonal antibody nBT062 conjugated to cytotoxic maytansinoids has selective cytotoxicity against CD138-positive multiple myeloma cells in vitro and in vivo. Clin Cancer Res. 2009;15(12):4028-4037.16. Jagannath S, Chanan-Khan A, Heffner LT, et al. BT062, an

antibody-drug conjugate directed against CD138, shows clinical activity in patients with relapsed or relapsed/refractory multiple myeloma. Presented at: the 2011 American Society of Hematol-ogy Annual Meeting; December 10-13, 2011; San Diego, CA. Abstract 305.17. Kelly KR,Chanan-Khan A, Somlo G,et al. Indatuximab ravtansine (BT062) in combination with lenalidomide and low-dose dexamethasone in patients with relapsed and/or refractory multiple myeloma: clinical activity in len/dex-refractory patients.Presented at: the 2013 American Society of Hematology Annual Meeting; December 7-10, 2013; New Orleans, LA. Abstract 758.18. Hideshima T, Richardson PG, Anderson KC. Mechanism of action of proteasome inhibitors and deacetylase inhibitors and the biological basis of synergy in multiple myeloma. Mol Cancer Ther. 2011;10(11):2034-2042.19. Dimopoulos M, Siegel DS, Lonial S, et al. Vorinostat or pla-cebo in combination with bortezomib in patients with multiple myeloma (VANTAGE 088): a multicentre, randomised, dou-ble-blind study. Lancet Oncol. 2013;14(11):1129-1140.20. San-Miguel JF, Hungria VT, Yoon SS, et al. Panobinostat plus bortezomib and dexamethasone versus placebo plus borte-zomib and dexamethasone in patients with relapsed or relapsed and refractory multiple myeloma: a multicentre, randomised, double-blind phase 3 trial. Lancet Oncol. 2014;15(11):1195-1206.21. Shah JJ, Feng L, Manasanch EE, al. Phase I/Ib trial of the efficacy and safety of combination therapy with lenalidomide/bortezomib/dexamethasone (RVD) and panobinostat in trans-plant-eligible patients with newly diagnosed multiple myeloma. Presented at: the 2014 American Society of Hematology Annual Meeting; December 6-9, 2014; San Francisco, CA. Abstract 33.22. Kaufman JL, Zimmerman T, Rosenbaum CA, et al. Phase I study of the combination of carfilzomib and panobinostat for patients with relapsed and refractory myeloma: a multiple myelo-ma research consortium (MMRC) clinical trial. Presented at: the 2014 American Society of Hematology Annual Meeting; Decem-ber 6-9, 2014; San Francisco, CA. Abstract 32. 23. Chari A, Cho HJ, Parekh S, et al. A phase II, single-center, open-label study of oral panobinostat in combination with lena-lidomide and weekly dexamethasone in patients with multiple myeloma. Presented at: the 2014 American Society of Hematol-ogy Annual Meeting; December 6-9, 2014; San Francisco, CA. Abstract 3486.24. Richardson PG, Schlossman RL, Alsina M, et al. PANORA-MA 2: panobinostat in combination with bortezomib and dexa-methasone in patients with relapsed and bortezomib-refractory myeloma. Blood. 2013;122(14):2331-2337.25. Lonial S, Shah JJ, Zonder J, et al. Prolonged survival and improved response rates with ARRY-520 (filanesib) in relapsed/refractory multiple myeloma (RRMM) patients with low α-1 acid glycoprotein (AAG) levels: results from a phase 2 study. Present-ed at: the 2013 American Society of Hematology Annual Meet-


· Hematology ·

ing; December 7-10, 2013; New Orleans, LA. Abstract 285.26. McMillin DW, Ooi M, Delmore J, et al. Antimyeloma activ-ity of the orally bioavailable dual phosphatidylinositol 3-kinase/mammalian target of rapamycin inhibitor NVP-BEZ235. Cancer Res. 2009;69(14):5835-5842.27. Spencer A, Yoon SS, Harrison SJ, et al. The novel AKT in-hibitor afuresertib shows favorable safety, pharmacokinetics, and clinical activity in multiple myeloma. Blood. 2014;124(14):2190-2195.28. Brault L, Gasser C, Bracher F, et al. PIM serine/threonine kinases in the pathogenesis and therapy of hematologic malig-nancies and solid cancers. Haematologica. 2010;95(6):1004-1015.29. Raab MS, Ocio EM, Thomas SK, et al. Phase I study update of the novel pan-pim kinase inhibitor LGH447 in patients with relapsed/refractory multiple myeloma. Presented at: the 2014 American Society of Hematology Annual Meeting; December 6-9, 2014; San Francisco,CA. Abstract 301.30. Tai YT, Landesman Y, Acharya C, et al. CRM1 inhibition induces tumor cell cytotoxicity and impairs osteoclastogenesis in multiple myeloma: molecular mechanisms and therapeutic im-plications. Leukemia. 2014;28(1):155-165.31. Chen C, Gutierrez M, de Nully Brown P, et al. Anti-tumor activity of selinexor (KPT-330), an oral selective inhibitor of nuclear export (SINE), ± dexamethasone in multiple myeloma. Preclinical Models and Translation in Patients with Multiple My-eloma Presented at: the 19th Congress of the European Hema-tology Association; June 12-15, 2014; Milan, Italy. Abstract P953.32. Raje N, Vogl D, Hari P, et al. ACY-1215, a selective histone deacetylase (HDAC) 6 inhibitor: interim results of combination therapy with bortezomib in patients with multiple myeloma (MM). Presented at: the 2013 American Society of Hematolo-gy Annual Meeting; December 7-10, 2013; New Orleans, LA. Abstract 759.33. Raje N, Vogl D, Bensinger W, et al. Ricolinostat (ACY-1215), the first selective histone deacetylase 6 inhibitor, is active and well tolerated in combination with lenalidomide or bortezo-mib in patients with refractory myeloma. Presented at: the 19th Congress of the European Hematology Association; June 12-15, 2014; Milan, Italy. Abstract P358.


· genomics ·

Clinical Applications and Limitations of Next-Generation Sequencing

Reva Kakkar Basho, MD, Agda Karina Eterovic, PhD, and FundaMeric-Bernstam, MD

IntroductionPersonalized cancer therapy requires the use of molecular diag-nostics to tailor treatments to individuals. At this time, only a few molecular biomarker-based therapies, such as erlotinib in EGFR-mutated lung cancer and vemurafenib in BRAF-mutat-ed melanoma, have been widely accepted.1,2 Next-generation sequencing (NGS) has the potential to revolutionize oncology through the classification of tumors and identification of bio-markers that can predict response to individualized therapy.

Until recently, the Sanger sequencing method was the most widely used sequencing method, and resulted in the only com-plete human genome sequence.3 This technology relies on incor-poration of chain-terminating dideoxynucleotides during DNA replication.4 Fluorescently labeled terminators, capillary electro-phoresis separation, and laser signal detection have improved the throughput of Sanger sequencing.5 However, it remains labor-intensive, time-consuming, and expensive when done in large scale.6 Therefore, the demand for faster, more accurate, and more cost-effective genomic information has led to the develop-ment of NGS methods.

NGS methods are high-throughput technologies with capabil-

ities of sequencing large numbers of different DNA (massively parallel) sequences at once. NGS technologies monitor the se-quential addition of nucleotides to immobilized DNA templates generated from target tissue.7 Unfortunately, the increased throughput of NGS reactions comes at the cost of shorter se-quences, as most sequencing platforms (Illumina, Roche, SoLiD) offer shorter read lengths (30–400 bp) than the conventional Sanger-based method.8 These shorter sequences are then assem-bled into longer sequences such as complete genomes.

Common approaches to DNA sequencing include whole-ge-nome sequencing, whole-exome sequencing, targeted exome sequencing, and “hotspot” sequencing. Whole-genome sequenc-ing sequences the complete genome of a sample (ie, chromosom-al DNA and mitochondrial DNA, which includes intronic and exonic regions). Whole-exome sequencing is a technique that sequences all of the protein-coding genes (ie, all exons in the genome). Targeted exome sequencing uses target-enrichment methods to capture genes of interest. This approach is becoming increasingly popular in oncology for assessing the full sequence of cancer-related gene panels. Targeted exome sequencing also facilitates sequencing at a greater depth, and thus the identifica-tion of subclonal mutations. Alternately, rather than sequencing the full sequence of selected genes, only selected regions of selected genes can be sequenced, focusing on cancer gene “hotspots”—re-gions with recurrent mutations. Although hotspot mutation test-ing facilitates large-scale sequencing of many samples, it does limit the knowledge that is acquired through sequencing because it limits the evaluation to small regions in selected genes. Consequently, it increases the possibility of omitting relevant mutations for which evaluation is not being conducted, thus limiting the clinical knowledge that is gained through NGS. Despite its drawbacks, it is becoming a widely accepted form of NGS.

In addition to nucleotide change detection (mutations and small insertions and deletions), NGS allows for DNA-copy number predictions. Further, NGS technology also can be ap-plied to RNA in order to evaluate the transcriptome of a tumor. RNA-sequencing (RNA-seq) allows for the assessment of gene expression and transcriptional splice variant analysis in addition

Abstract

Growing interest in personalized cancer therapy has led

to numerous advances in the field of cancer genomics.

Next-generation sequencing (NGS) is one such develop-

ment that has allowed for lower cost, higher-throughput

genome sequencing. However, the vast number and

types of genomic aberrations found in cancer means

that interpretation of the data generated by NGS requires

substantial analytical complexity. Here, we discuss the

clinical applications of NGS and the obstacles that must

be overcome prior to widespread use in clinical decision

making.

Key words: Next-generation sequencing, review,

genomics, cancer


· genomics ·

to detection of mutations. A typical NGS work flow from sample collection to the capture and sequencing of genes of interest and data analysis is illustrated in Figure 1.

Identification of Cancer GenomicsIn recent years, NGS has been used to characterize genomic alterations such as mutations, insertions/deletions, and copy number changes, and the frequency with which they occur in various tumor types. Efforts such as the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA) aim to catalog such genomic alterations across many tumor types.9,10 However, the wealth of information that is gener-ated through this process unveils potentially the largest hurdle of genomic medicine: How do we analyze the abundance of infor-mation that is generated to make informed decisions regarding therapy? Analysis of cancer genomes reveals that most tumors contain multiple alterations.11-14 As a result, it is very important to distinguish the “driver” mutations that contribute to tumor development from the “passengers” that do not.15

Comparison of sequenced genomes to reference genomes allows for the identification of genome alterations that may be relevant in disease development and progression.16 However, such comparison depends on the establishment of extensive and accurate reference genomes, which is a cumbersome task. Further, the complexity of genomic aberrations in cancer makes it difficult to rely on standard reference genomes.8 Therefore, simplified methods of identifying driver mutations are required. Several theories exist for the potential identification of driver mutations. One such hypothesis is that mutations that occur with higher frequency are more likely to contribute to tumor development and growth.17 Genome-wide association studies (GWAS) aim to compare the incidence of commonly known sin-gle nucleotide polymorphisms (SNPs) in genomes from patients with and without a specific disease. SNPs that occur at a higher frequency in the diseased population are identified as potentially causative. If a specific mutation is not found in high frequency, but the same molecular pathway contains frequent genomic al-terations, those alterations may also be relevant.

Another theory is that alterations present in both germline

and tumor tissue of the same patient are likely to be integral to tumor development. For example, some mutations in can-cer-predisposition genes such as BRCA1/2 clearly do contribute to the development and maintenance of cancer. This, however, requires that germline tissue be collected in each patient. Yet an-other theory is that sequencing DNA and RNA from the same sample will identify mutations that subsequently alter expres-sion, and are thus significant. However, all of these methods only begin to narrow the spectrum of genomic alterations that may be clinically relevant. Chromosome-scale changes and epigenomic changes cannot be evaluated in this manner. Many studies are now focusing on the development of bioinformatic tools to aid in the identification of driver mutations.18

Clinical Decision SupportOnce driver mutations have been identified in a tumor, the next step is to assess whether those mutations are “actionable.” Ac-tionable alterations affect the function of a cancer-related gene and can be targeted with approved or investigational therapies.Assessing functionality is a difficult task and requires predictive knowledge of genome alterations. Often, early-phase studies are used to assess the role various mutations based on rates of re-sponse to targeted therapies. However, enrollment in such stud-ies requires that physicians be aware of genome alterations and potential trials for each patient.

A survey of 160 physicians at a tertiary-care National Cancer Institute (NCI)-designated comprehensive cancer center revealed that a considerable percentage of physicians have low confidence in their genomic knowledge.19 As a result, many institutions have instituted tumor boards to increase awareness of and access to appropriately targeted therapies.20 Similarly, the American Soci-ety of Clinical Oncology has monthly presentations that explore current treatment strategies and novel therapeutics in various tumor types to increase knowledge of newer targeted therapies. Other trials such as NCI Molecular Analysis for Therapy Choice Program (NCI-MATCH) has streamlined the decision making by designing algorithms and creating rules to designate alterations as actionable, and to prioritize targets if more than one target is iden-tified. In this signal-seeking trial, 3000 patients will undergo tu-mor NGS to match genomic alterations to smaller histology-agnos-tic phase 2 trials of Food and Drug Administration (FDA)-approved agents (in other diseases) and investigational therapeutics (Figure 2).

If a response signal is seen in early-phase trials, the clinical relevance and therapeutic implications of actionable mutations can be assessed through thoughtful biomarker-driven research. Hypothesis-driven preclinical studies and clinical trials to as-sess targeted therapies in various tumor types can be designed. Such trials allow for the recruitment of selected patients into clinical trials to enhance the assessment of those targeted ther-apies. Ultimately, the goal is to implement randomized clinical trials to assess molecularly targeted therapy in a biomarker-se-

Practical Application

• Provideabriefintroductiontothemethodsofnext-generationsequencing(NGS)

• IdentifyclinicalapplicationsofNGSincludingtheidentificationofvariousmolecularaberrationsindifferenttumortypes,theresultantdesignofmolecularbiomarker-drivenclinicaltrials,andthepoten-tialtoidentifymolecularaberrationsthatleadtodiseaseprogres-sionandresistance

• IdentifylimitationsofNGS,includingtheneedforextensiveanalyticcapabilities,thedifficultiesinidentificationofdrivermutations,andtheconfoundingfactoroftumorheterogeneity

• IdentifypotentialfutureapplicationsofNGS


CliniCal appliCations and limitations of next-Generation sequenCinG

lected or biomarker-stratified fashion. The Adjuvant Lung Can-cer Enrichment Marker Identification and Sequencing Trials (ALCHEMIST) is an example of such a trial in which patients with early-stage adenocarcinoma of the lung are screened for EGFR and ALK mutations, and subsequently randomized into trials of relevant targeted therapy if mutations are found. With NGS technology, a high throughput of patients can undergo test-ing to assess their eligibility for clinical trials within a clinically reasonable timeframe.

Genomic Evolution and Intertumor and IntratumorHeterogeneityFurther complicating the implementation of genomic medicine is the fact that driver mutations can evolve during the course of cancer. As tumors are treated or as they grow, a variety of ac-quired genomic alterations may emerge. For example, melanoma treated with BRAF or MEK inhibitors has been shown to acquire BRAF amplifications and downstream alterations that lead to re-

activation of the MAP kinase pathway.21-23 Similarly, increased signaling via the phosphatidylinositol 3-kinase/Akt pathway may contribute to trastuzumab resistance in HER2-positive breast cancer.24 Thus, the dynamic nature of cancer requires that ge-nomic information be applicable in real time in order for clinical use. As a result, archived tissue from biopsies may not be relevant for therapy selection at the time of progression.

In addition to genomic evolution, tumors may also develop intertumor and intratumor heterogeneity. Intertumor heteroge-neity refers to differences in alterations of tumors at different sites, while intratumor heterogeneity refers to differences in al-terations within a tumor. Both intertumor and intratumor het-erogeneity can further complicate the determination of relevant mutations because it means that tissue for NGS has to be ob-tained from relevant sites as well as at a relevant time point in the treatment course. This can result in repeated biopsies. Addi-tionally, metastatic sites such as bone and brain can be difficult to test. However, comparison of primary tumors with matched

Figure 1. Overview of a Potential Next-Generation Sequencing Work Flow

(1) Slides are cut from tumor samples embedded in paraffin blocks. For each tumor sample, hematoxylin and eosin stains are performed and cellularity is assessed. Matching peripheral blood is also collected for each patient. Genomic DNA is isolated from both the formalin-fixed, paraffin-embedded tissue and blood. Alternately, frozen fresh tissue samples as well as other normal DNA sources such as saliva, buccal swab, or normal tissue can be used. (2) DNA is fragmented and libraries are made by ligating indexed adaptors (Indexed Libraries) that allow for sample pooling. Hybridization with probes is performed; the captured DNA is washed and amplified and proceeded to DNA sequencing. (3) Captured DNA is sequenced; after sequencing, samples are demultiplexed, or separated, and the raw data is submitted to data analysis for mutations and copy number variations identification. (4) The genomic alterations are reviewed and alterations in actionable genes are identified. Functional impact of alterations in actionable genes is assessed and therapeutic implications of known and predicted functional alterations are determined.

Modified from Chen et al. Clin Chem.2015.33

1

DNA Isolation Library Prep and Capture Sequencing and Data Analysis Determining Therapy

2 3 4

Paraffin Block

Cellularity (60%)

FFPE Slides

Blood

GenomicDNA

Tumor area

Fragmented DNA Indexed Libraries

T200probes

Hybridlibrary-probes

CaptureAmplified DNA

AlignmentMutations

CNVs

Sequencing

Data Analysis

Determine functionalconsequences of alterations

Prioritize mutations/targetsIdentify potential targeted therapies

FDA-approved genomically-matched therapy in same tumor type?

Consider clinical trials using genotype-relevant drugs

NO

Determine if alterationsin actionable genes


· genomics ·

metastases has shown relatively high concordance in their mu-tational profiles, suggesting that additional biopsies may not al-ways be necessary.25,26

Although genomic evaluation makes it difficult to identify rel-evant aberrations, recognizing genomic evolution is a powerful tool to better understand the progression of cancer. Genomic analysis of cancer at different stages, from precancerous lesions to localized tumors to metastatic disease, can identify genetic events that drive tumor growth. For example, genomic studies that analyze genomic alterations in breast ductal carcinoma in situ (DCIS) can help to design a predictive model for lesions that are likely to progress to carcinoma versus those that are not.27 Sim-ilarly, NGS-based analysis of drug-resistant cells can help identify mechanisms of resistance. For instance, sequencing tumors from patients with estrogen receptor (ER)–positive breast cancer that recurred or progressed after treatment with antiestrogen therapy revealed mutations in the ESR1 gene; these mutations were con-stitutively active.28 Interestingly, ESR1 gene mutations were not seen in TCGA analysis, which included primary tumors only.11 Together, these studies suggest that activating mutations in the ESR1 gene are an acquired mechanism of resistance to antiestro-gen therapy. Similarly, RNA sequencing of tamoxifen-sensitive and -resistant breast cancer cells revealed gene expression chang-

es implicating a series of resistance mechanisms that could be grouped in ER functions, cell cycle regulation, transcription/translation, and mitochondrial dysfunction.29

Future Applications and DirectionsSeveral additional applications of NGS are under development. One potential future application of NGS is the evaluation of circulating tumor cells or free-plasma DNA to detect early re-lapse or residual cancer.20 Once tumor-specific genome alter-ations have been identified by NGS, PCR assays could be used to detect circulating tumor cells or free-plasma DNA harboring the same alterations. Disease status, drug responsiveness, and re-lapse could be serially assessed. The monitoring strategy would, however, require that the mutation being tested be present in all tumor cells and remain present throughout the course of disease. As discussed previously, due to genomic evolution and tumor heterogeneity, such mutations are difficult to identify. Optimal-ly, mutations used for monitoring would be truncal mutations—mutations in the “trunk-branch” model of heterogeneity, and thus representing ubiquitous driver mutations present in every tumor subclone and region.31 However, serial monitoring could also identify new alterations that occur under the selection pres-sure of treatment, which could give insights into mechanisms of

acquired resistance. Another potential application of NGS

is to improve the diagnosis of cancer. Poor tissue sampling and processing can often make a histological diagnosis difficult. Ad-ditionally, mixed tumor phenotypes can sometimes make it difficult to determine the origin of the tumor. However, NGS-based analysis of tissue can be performed on small amounts of viable tissue and is accurate when sufficient information re-garding causative mutations is known. An evaluation of 143 benign and malignant thyroid nodules revealed that genotyping of fine-needle aspiration (FNA) samples of the nodules using a broad NGS panel provided high sensitivity and specificity in the diagnosis of these samples.32 Such diagnoses would require clinical validation prior to widespread use. Furthermore, as the genomics of different tumors become apparent, NGS can be used to identify dif-ferent molecular subtypes, which is already becoming commonplace with sarcoma fu-sion proteins.

Finally, NGS can identify molecular aberrations that render tumors exquisite-ly sensitive to certain therapies, resulting

Figure 2. Overview of NCI-MATCH Trial Design

A schematic of the NCI-MATCH trial design. Patient tumors undergo genetic sequencing and are assessed for actionable mutations. If found, patients are enrolled in smaller phase 2 trials of approved or investigational therapeutics until progression of disease. At the time of disease progression, patient tumors are again assessed for other actionable mutations. If found, patients are again enrolled in another phase 2 trial. If no further actionable mutations are found, patients are taken off study.

Figure adapted from Abrams et al. ASCO Educational Book. 2014.34

Genetic Sequencing

Actionable mutation detected

Progressivedisease (PD)1

Check for additional actionable mutations2

No additional actionable

mutations, or withdraw consent

Yes No

Stable disease,Complete or

partial response(CR +PR)1

Continue on study agent until

progression

Studyagent

Offstudy

PD

1CR, PR, SD, and PD as define by RECIST (solid tumors)2Rebiopsy; if additional mutations, offer new targeted therapy


CliniCal appliCations and limitations of next-Generation sequenCinG

in exceptional responses. Such extraordinary outcomes can im-prove our understanding of molecular features that can predict response to certain drugs. For this purpose, the NCI has un-dertaken the Exceptional Responders Initiative, through which tumors of exceptional responders will undergo DNA and RNA sequencing to define genetic alterations that might have resulted in such responses.

ConclusionNext-generation sequencing has opened a broad new area of research with the potential to revolutionize personalized cancer medicine. However, further development of this field requires real-time knowledge of genome alterations that can be used in clinical decision making. This requires a robust data infra-structure, continuous improvement in sequencing technology, development of analytical tools, and ongoing biomarker-driven preclinical and clinical trials. Ultimately, however, NGS data have the potential to guide clinicians in tailoring treatment to dynamic genomic changes in individual tumors.

Affiliations: Reva Kakkar Basho, MD, is from the Department of Cancer Medicine; Agda Karina Eterovic, PhD, is from the Department of Systems Biology; Funda Meric-Bernstam, MD, is from the Departments of Investigational Cancer Therapeutics, Surgical Oncology, and the Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer Therapy at The University of Texas MD Anderson Cancer Center, Houston, TX.Disclosures: Drs Basho and Eterovic have no relevant conflicts of interest to disclose. Dr Meric-Bernstam has served as a con-sultant or on a paid advisory board for Novartis and Roche; has received grants from Novartis, AstraZeneca, Taiho Pharmaceuti-cal, Genentech, Calithera Biosciences, Debiopharm, and Bayer; has received honoraria from Genentech, Roche Diagnostics, and Sysmex Corporation; and has served on an advisory committee or review panel for Genentech, Novartis, and Roche.Funding support: This work was supported in part by the Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer Therapy and the MD Anderson Cancer Center Support grant (P30 CA016672).Address correspondence to: Funda Meric-Bernstam, MD, UT MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 455, Houston, TX 77030. Phone: 713-792-3737; fax: 713-563-0566; email: [email protected].

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2. Chapman PB, Hauschild A, Robert C, et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med. 2011;364(26):2507-2516.3. International Human Genome Sequencing Consortium. Finishing the euchromatic sequence of the human genome. Nature. 2004;431(7011):931-945.4. Sanger F, Nicklen S, Coulson AR. DNA sequencing with chain-terminating inhibitors. Proc Natl Acad Sci USA. 1977;74(12):5463-5467.5. Rizzo JM, Buck MJ. Key principles and clinical applications of “next-generation” DNA sequencing. Cancer Prev Res. 2012;5(7):887-900.6. Metzker ML. Emerging technologies in DNA sequencing. Genome Res. 2005;15(12):1767-1776.7. Metzker ML. Sequencing technologies—the next generation.Nat Rev Genet. 2010;11(1):31-46.8. Ulahannan D, Kovac MB, Mulholland PJ, et al. Technical and implementation issues in using next-generation sequencing of cancers in clinical practice.Br J Cancer. 2013;109(4):827-835.9. International Cancer Genome Consortium; Hudson TJ, Anderson W, Artez A, et al. International network of cancer genome projects. Nature. 2010;464(7291):993-998.10. Cancer Genome Atlas Research Network; Weinstein JN, Collisson EA, Mills GB, et al. The Cancer Genome Atlas Pan-Cancer analysis project. Nat Genet. 2013;45(10):1113-1120.11. Cancer Genome Atlas Network. Comprehensive molecular portraits of human breast tumours. Nature. 2012;490(7418):61-70.12. Cancer Genome Atlas Network. Comprehensive molecular characterization of human colon and rectal cancer. Nature. 2012;487(7407):330-337.13. Cancer Genome Atlas Network. Integrated genomic analyses of ovarian carcinoma. Nature. 2011;474(7353):609-615.14. Shah SP, Roth A, Goya R, et al. The clonal and mutational evolution spectrum of primary triple-negative breast cancers. Nature. 2012;486(7403):395-399.15. Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144(5):646-674.16. Nielsen R, Paul JS, Albrechtsen A, Song YS. Genotype and SNP calling from next-generation sequencing data. Nat Rev Genet. 2011;12(6):443-451.17. Sjoblom T, Jones S, Wood LD, et al. The consensus coding sequences of human breast and colorectal cancers. Science. 2006;314(5797):268-274.18. Merid SK, Goranskaya D, Alexeyenko A. Distinguishing between driver and passenger mutations in individual cancer genomes by network enrichment analysis. BMC Bioinformatics. 2014;15:308.19. Gray SW, Hicks-Courant K, Cronin A, et al. Physicians’ attitudes about multiplex tumor genomic testing. J Clin Oncol. 2014;32(13):1317-1323.20. Schwaederle M, Parker BA, Schwab RB, et al. Molecular


· genomics ·

tumor board: the University of California-San Diego Moores Cancer Center experience. Oncologist. 2014;19(6):631-636.21. Wagle N, Van Allen EM, Treacy DJ, et al. MAP kinase pathway alterations in BRAF-mutant melanoma patients with acquired resistance to combined RAF/MEK inhibition. Cancer Discov. 2014;4(1):61-68.22. Mao Y, Chen H, Liang H, et al. CanDrA: cancer-specific driver missense mutation annotation with optimized features. PLoS One. 2013;8(10):e77945.23. Van Allen EM, Wagle N, Sucker A, et al. The genetic landscape of clinical resistance to RAF inhibition in metastatic melanoma. Cancer Discov. 2014;4(1):94-109.24. Nahta R, Yu D, Hung MC, et al. Mechanisms of disease: understanding resistance to HER2-targeted therapy in human breast cancer. Nat Clin Pract Oncol. 2006;3(5):269-280.25. Meric-Bernstam F, Frampton GM, Ferrer-Lozano J, et al. Concordance of genomic alterations between primary and recurrent breast cancer. Mol Cancer Ther. 2014;13(5):1382-1389.26. Meric-Bernstam F, Frampton GM, Ferrer-Lozano J, et al. Concordance of genomic alterations between primary and recurrent breast cancer. Mol Cancer Ther. 2004;13(5):1382-1389.27. Kaur H, Mao S, Shah S, et al. Next-generation sequencing: A powerful tool for the discovery of molecular markers in breast ductal carcinoma in situ. Expert Rev Mol Diagn. 2013;13(2):151-165.28. Segal CV, Dowsett M. Estrogen receptor mutations in breast cancer—new focus on an old target. Clin Cancer Res. 2014;20(7):1724-1726.29. Huber-Keener KJ, Liu X, Wang Z, et al. Differential gene expression in tamoxifen-resistant breast cancer cells revealed by a new analytical model of RNA-Seq data. PLoS One. 2012;7(7):e41333.30. McBride DJ, Orpana AK, Sotiriou C, et al. Use of cancer-specific genomic rearrangements to quantify disease burden in plasma from patients with solid tumors. Genes Chromosom Cancer. 2010;49(11):1062-1069.31. Yap TA, Garlinger M, Futreal PA, et al. Intratumor heterogeneity: seeing the wood for the trees. Sci Transl Med. 2012;4(127):127ps10.32. Nikiforov YE, Carty SE, Chiosea SI, et al. Highly accurate diagnosis of cancer in thyroid nodules with follicular neoplasm/suspicious for a follicular neoplasm cytology by ThyroSeq v2 next-generation sequencing assay. Cancer. 2014;120(23):3627-3634.33. Chen K, Meric-Bernstam F, Zhao H, et al. Clinical actionability enhanced through deep targeted sequencing of solid tumors [published online January 27, 2015]. Clin Chem. 2015.pii:clinchem.2014.231100. 34. Abrams J, Conley B, Mooney M, et al. National Cancer Institute’s Precision Medicine Initiatives for the New National Clinical Trials Network. ASCO Educational Book. 2014;71-76.


· breast cancer ·

The PI3K Pathway as a Therapeutic Target in Breast Cancer

Cynthia X. Ma, MD, PhD

Function of PI3K Pathway and Alterations in Breast CancerClass I phosphatidylinositol-3-kinases (PI3Ks) are heterodimers of a 110 KD catalytic subunit (p110α, p110β, p110γ or p110δ) and a regulatory subunit, which receive activation signals from receptor tyrosine kinases (RTKs), RAS, and G protein–coupled receptors (Figure 1).1 Activated PI3K catalyzes the conversion of phosphatidylinositol bisphosphate, PI(4,5)P2, to phosphatidyli-nositol triphosphate, PI(3,4,5)P3, which recruits phosphoinositi-de-dependent kinase-1 (PDK1) and protein kinase B, also known as AKT, leading to a cascade of signaling events that regulate cell survival, proliferation, metabolism, motility, and genomic stabil-ity.1 This pathway is also important in regulating tumor-associat-ed immune response and angiogenesis.2

Genetic or epigenetic alterations in PI3K pathway com-ponents, including activating mutations in PIK3CA, the gene encoding the p110α catalytic subunit of PI3K, and AKT1, and loss-of-function mutations or epigenetic silenc-ing of phosphatase and tensin homolog (PTEN), the neg-

ative regulator of the pathway, are commonly observed in cancer, leading to activation of PI3K pathway signaling. In estrogen receptor–positive (ER+) breast cancer, mutations in PIK3CA represent the most common genetic events, occurring at a frequency of 30% to 50%. Less commonly observed are mu-tations in PTEN (2% to 4%), AKT1 (2% to 3%), and phospha-tidylinositol-3-kinase regulatory subunit alpha (PIK3R1: 1% to 2%).3,4 Similar findings were observed in HER2-positive breast cancer.4 In contrast, triple-negative breast cancer (TNBC) is asso-ciated with a lower incidence of PIK3CA mutations (<10%), but much higher frequency of loss of PTEN (about 30% to 50%).4 The frequent occurrence of PI3K pathway activation makes it an attractive therapeutic target in breast cancer.

Targeting the PI3K Pathway in ER+ Breast Cancer The importance of PIK3CA mutation in the etiology of ER+ breast cancer is supported by several lines of evidence. A major-ity of the mutations, including the 3 hotspot mutations E542K, E545K, and H1047R, are missense “activating” mutations that cluster in the evolutionarily conserved accessory domain and the kinase domain.5 The oncogenic property of the common PIK3CA mutations was demonstrated by their ability to induce cellular transformation and xenograft tumor formation when overexpressed in mammary epithelial cells.6,7 In preclinical stud-ies, cancer cells carrying PIK3CA mutation depend on the alpha catalytic subunit of PI3K for cell growth.8 Although the presence of PIK3CA mutation in ER+ breast cancer has not been associat-ed with de novo resistance to endocrine therapy,9 upregulation of PI3K pathway signaling has been observed in tumor cells grown under long-term estrogen deprivation in experimental models.10 In clinical samples, higher PI3K activity, based on the levels of phosphorylated forms of AKT, mammalian target of rapamycin (mTOR), glycogen synthase kinase 3 (GSK3), and the ribosomal protein S6 kinase (S6K), and loss of PTEN was associated with a lower ER level and with luminal B status.11 Importantly, a syn-thetic lethal interaction, or synergistic apoptotic induction, was observed between estrogen deprivation and inhibition of PI3K, either molecularly by knockdown of PIK3CA or pharmacologi-cally with inhibitors of PI3K or AKT, in ER+ breast cancer cell

Abstract

The phosphatidylinositol-3-kinase (PI3K)/Akt/mammalian

target of rapamycin (mTOR) signaling pathway is crucial

to many aspects of cell growth and survival. The rec-

ognition of its importance in tumorigenesis and cancer

progression has led to the development of a number of

agents that target various components of this pathway as

cancer therapeutics. Promising results with these agents

have been observed in the treatment of advanced estro-

gen receptor–positive (ER+) breast cancer. However, the

therapeutic efficacy of single-agent PI3K pathway inhib-

itors is likely limited by feedback regulations among its

pathway components and crosstalk with other signal-

ing pathways. There are ongoing efforts to investigate

predictors of response and mechanisms of treatment

resistance.

Key words: phosphatidylinositol-3-kinase, PI3K, breast

cancer, targeted therapy


· breast cancer ·

lines.8,12 These studies provided the rationale for combining en-docrine therapy and inhibitors of PI3K pathways in ER+ breast cancer.

Initial success from combing endocrine therapy with inhibi-tors against the PI3K pathway was demonstrated in clinical trials of rapamycin analogues for the treatment of advanced ER+ breast

cancer resistant to an aromatase inhibitor (AI). These agents in-hibit the activity of mTORC1 by interacting with FKBP12. In the TAMRAD trial, a randomized phase 2 trial of tamoxifen with or without everolimus in 111 postmenopausal women with AI-resistant, ER+, advanced breast cancer, the combination arm was associated with a significantly improved progression-free sur-vival (PFS; 4.5 vs 8.6 months; hazard ratio [HR] = 0.54; P =.002) and overall survival (OS).13 Similarly, BOLERO-2, a phase 3 trial of exemestane in combination with either everolimus or place-bo in postmenopausal women with advanced ER+, HER2-neg-ative (HER2-) breast cancer resistant to letrozole or anastrozole, demonstrated a significant improvement in PFS (3.2 months in the placebo/exemestane arm vs 7.8 months in the everolimus/exemestane arm; HR = 0.45; P <.0001),14,15 leading to FDA ap-proval of this combination in AI-resistant, advanced ER+ disease. However, the OS was no different in both arms (26.6 months in the placebo/exemestane arm vs 31 months in the everolimus/exemestane arm; HR = 0.89; P =.14).15 The OS data were disap-pointing; however, this may not be too surprising, as rapalogs lack the ability to inhibit mTORC2, leading to feedback upregu-lation of AKT activity and treatment failure.16 Nonetheless, the improvement in PFS is meaningful, and everolimus remains a treatment option for the AI-resistant population.

Everolimus was also combined with fulvestrant in a single-arm, phase 2 trial in AI-resistant, metastatic, ER+ breast cancer.17 Among the 31 evaluable patients, the objective response rate was 13% and the clinical benefit rate was 49%, with median time to progression (TTP) of 7.4 months, suggesting clinical efficacy. However, a randomized trial is required to define the activity of this combination in AI-resistant, ER+ breast cancer.

A number of agents that target the PI3K pathway (Table 1), in-cluding mTOR kinase inhibitors, direct PI3K or AKT inhibitors, and dual inhibitors of PI3K and mTOR, are in clinical develop-ment and have the potential to more effectively inhibit the PI3K pathway than rapamycin analogues.18 The mTOR kinase inhibi-tors and AKT inhibitors are in early phases of clinical trial devel-opment, while PI3K inhibitors have advanced to phase 3 trials and have shown promise in early-phase trials for ER+ disease.19

PI3K inhibitors are classified into pan-PI3K inhibitors and iso-form-specific inhibitors, depending on their specificities to the 4 isoforms of the p110 catalytic domain, p110α, p110β, p110γ, and p110δ. Isoform-specific inhibitors may have the advantage of more effective isoform inhibition at tolerable doses than pan-PI3K inhibitors. However, patient selection may be particular-ly important for these agents, as cancers may rely on different p110 isoforms for cell growth. For example, p110α is critical for PIK3CA-mutant breast cancers, while p110β appears to be par-ticularly important for those with loss of PTEN. Therefore, p110α-specific inhibitors may not be effective in tumors deficient of PTEN.

Early trials of PI3K inhibitors have shown promising activity in

FIGURE 1. PI3K Pathway Signaling

RTK

PI3K

p85

mTORC2AKT

p110PDK1

S6K

S6elF4B elF4E

4EBP1

Tuberin

AMPK LKB1Rheb

mTORC1

GSK3FOXOBAD

ASK1

p p

p

IRS1

PI(4,5)P2ras

PI(4,5)P2

SHIP-1/2

PI(3,4)P2 PI(3)P

INPP4BPTEN

Class IA PI3K is composed of a p85 regulatory subunit and a p110 catalytic subunit. The inhibitory effect of p85 on the catalytic subunit is released following activation of the receptor tyrosine kinase by ligand binding, or by RAS. PI3K converts phosphatidylinositol bisphosphate, PI(4,5)P2, to phosphatidylinositol triphosphate, PI(3,4,5)P3, which serves as the docking sites for the membrane localization of the PH domain-containing molecules including phosphoinositide-dependent kinase-1 (PDK1) and AKT. PDK1 phosphorylates AKT at threonine 308. Mammalian target of rapamycin complex 2 (mTORC2) phosphorylates AKT at serine 473, leading to full activation of AKT, which phosphorylates and inhibits tuberous sclerosis complex, causing accumulation of Rheb GTP and activation of mammalian target of rapamycin complex 1 (mTORC1). S6 kinase (S6K1) and eukaryotic translation initiation factor 4E-binding protein 1 (4E-BP1) are important to protein synthesis. AKT also phosphorylates glycogen synthase 3β (GSK3β), Bcl-2-associated agonist of cell death (BAD), the forkhead transcription factors (FOXO), and other molecules. Phosphatase and tensin homolog deleted on chromosome 10 (PTEN) dephosphorylates PI(3,4,5)P3 to the inactive diphosphate form, while inositol polyphosphate 4-phosphatase type II (INPP4B) removes the phosphate group at position 4 of the inositol ring from the inositol 3,4-bisphosphate, thus negatively regulating the PI3K pathway. In addition, a negative feedback loop exists between mTORC1 and AKT through S6K1 induced IRS1 phosphorylation.


PI3K Pathway as a theraPeutIc target In Breast cancer

ER+ breast cancer. In a phase 1b study of buparlisib, a pan-PI3K inhibitor, plus letrozole in patients with metastatic ER+ breast cancer refractory to endocrine therapy, 16 of 51 patients (31%) enrolled in the study derived clinical benefit (lack of disease pro-gression, ≥6 months).19 Buparlisib has also been combined with fulvestrant, with activity observed in a phase 1 trial that enrolled patients with metastatic ER+ breast cancer.20 The combination of buparlisib and fulvestrant is being evaluated in phase 3 trials, including BELLE-2 (NCT01610284) for AI-resistant, metastatic, ER+ breast cancer, and BELLE-3(NCT01633060) for AI-resis-tant, metastatic, ER+ breast cancer that has progressed on or after a mTOR inhibitor.

Pictilisib is the first pan-PI3K inhibitor for which results of randomized trials in ER+ breast cancer have been reported.21,22 OPPORTUNE is a preoperative window study that randomized 75 postmenopausal patients with newly diagnosed, operable, ER+, HER2-negative breast cancer at a 2:1 ratio to receive 2-week preoperative treatment with anastrozole plus pictilisib (n = 49, 44 evaluable) or anastrozole alone (n = 26, all evaluable), with the primary endpoint of inhibition of tumor-cell proliferation, as measured by change in Ki67 expression at surgery following 2-week treatment.21 A higher degree of Ki67 suppression was observed with the combination therapy (83.8%) compared with anastrozole alone (66%; P =.004), indicating a superior efficacy of the combination arm.21 The FERGI phase 2 study of pictil-isib plus fulvestrant versus fulvestrant plus placebo in patients with AI-resistant, ER+, advanced or metastatic breast cancer was reported at the 2014 San Antonio Breast Cancer Symposium (SABCS). The median PFS was 5.1 months (fulvestrant + pla-cebo arm) vs 6.6 months (fulvestrant + pictilisib arm; P =.0959), which did not differ statistically. However, in the progesterone receptor–positive (PR+) subgroup, the addition of pictilisib to fulvestrant resulted in an improvement of PFS from 3.7 months to 7.4 months (HR = 0.440; 95% CI, 0.281-0.689).22 In this trial, dose reductions of pictilisib due to skin and gastrointestinal (GI) toxicities were frequent, and few patients experienced the on-tar-get side effect of PI3K inhibition with hyperglycemia, arguing that perhaps the dose of pictilisib might not have been optimal. We await the release of the BELLE2 data, which is anticipated early 2015, and data from other trials of isoform-selective PI3K inhibitors to define the role of various PI3K inhibitors in the treatment of ER+ breast cancer.

Targeting the PI3K Pathway in HER2-Positive Breast CancerIt is well established that HER2-amplified tumors show signifi-cant dependence on the PI3K pathway, and the antitumor effect of HER2-targeted agents is at least in part mediated by inhibition of PI3K pathway activity.23 Preclinical data demonstrated that the presence of PIK3CA mutations in HER2-positive breast can-cer uncouples HER2 and PI3K signaling, rendering tumor cells resistant to HER2-targeted agents such as trastuzumab, while

dual targeting of the HER2 and PI3K pathways was effective in overcoming trastuzumab resistance.23

However, addition of the mTOR inhibitor everolimus to tras-tuzumab-containing chemotherapy regimens for the treatment of metastatic HER2+ breast cancer has led to disappointing results in clinical trials. In the setting of the treatment of trastuzumab- and taxane-resistant metastatic HER2+ breast cancer, addition of everolimus to the combination of trastuzumab and vinorelbine led to a statistically significant but small improvement in me-dian TTP (7.0 months with everolimus vs 5.8 months without everolimus; P <.01) in the randomized phase 3 BOLERO-3 tri-

TablE 1. PI3K Pathway Inhibitors in Clinical Trials

Rapalogs

RAD001 (everolimus) CCI-779 (temsirolimus) AP23573 (deforolimus)

mTOR kinase inhibitors

MLN0128 AZD2014 OSI-027 CC-223

Pan-PI3K inhibitors

GDC-0941 (pictilisib)BKM120 (buparlisib)XL147PX-866BAY 80-6946CH5132799

p110α-specific PI3K inhibitors

BYL719 (alpelisib) MLN1117GDC-0032 (taselisib, p110b sparing,also targets p110g and d)

p110β-specific PI3K inhibitors

AZD8186SAR260301GSK2636771

Dual PI3K/mTOR inhibitors

BEZ235BGT226XL765GDC-0980

AKT inhibitors

PerifosineMK2206XL418GDC-0068 (ipatasertib)GSK2141795GSK2110183AZD5363


· breast cancer ·

al, reported at the 2014 American Society of Clinical Oncology Annual Meeting.24 In the first-line metastatic setting, addition of everolimus to the combination of trastuzumab and paclitaxel showed no improvement in PFS (14.95 months with everolimus vs 14.49 months without everolimus) in the phase 3 BOLERO-1 trial, reported at the 2014 SABCS.25 However, in both trials, the ER-negative (ER-) population derived more benefit, arguing the potential role of everolimus in the ER- population.

Clinical trials of other PI3K pathway inhibitors are under way for the treatment of HER2+ breast cancer.26 In a phase 1b trial of buparlisib plus trastuzumab in patients with HER2+ advanced or metastatic breast cancer that progressed on trastuzumab-based therapy, the combination was well tolerated; at the recommend-ed phase 2 dosage, there were 2 (17%) partial responses and 7 (58%) patients had stable disease (≥6 weeks), suggesting clinical activity.27 A phase 2 study of this combination is ongoing to de-fine the role of PI3K inhibitors in the treatment of HER2+ breast cancer.

Targeting the PI3K Pathway in TNBCThe potential role of the PI3K pathway in the pathogenesis of TNBC is supported by the frequent detection of PTEN loss and the evidence of activated PI3K pathway signaling in this subtype of breast cancer in an analysis of The Cancer Genome Atlas (TCGA) samples.4 In preclinical studies, inhibitors against mTOR and AKT induced growth arrest of patient-derived xeno-graft (PDX) models of TNBC.28 In addition, in the phase 1 study of single-agent BKM120, a pan-PI3K inhibitor, a partial response was observed in a patient with TNBC.29 Further preclinical and clinical studies that define the role of PI3K in TNBC are under way. However, frequent mutations or copy number changes in genes important for cell cycle arrest or apoptosis, such as RB, MYC, and TP53, likely limit the antitumor activity of PI3K path-way inhibitors in this tumor type. Rational combination thera-pies likely are needed. Of particular interest is the discovery that the PI3K pathway plays an important role in maintaining the genomic stability, and that inhibitors of the PI3K pathway may increase DNA damage and sensitize TNBC to inhibitors of poly ADP ribose polymerase (PARP).30,31 The combination of inhibi-tors against PI3K and PARP is being tested in clinical trials for the treatment of advanced TNBC.

Adverse Events of PI3K Pathway InhibitorsIn general, PI3K pathway inhibitors including mTOR, AKT, and PI3K inhibitors have been shown to be well tolerated. Common adverse events (AEs) associated with everolimus include stoma-titis, rash, fatigue, GI side effects, pneumonitis, and hyperglyce-mia. However, most of these AEs are grade 1 and 2. Among these AEs, stomatitis is the most common cause for dose interruption/dosage adjustment. In the BOLERO 2 trial, stomatitis occurred in 59% of patients (8% grade 3).32 Everolimus-induced stomatitis

often presents as aphthous-like ulcers that develop acutely within the first 2 weeks of treatment and quickly resolves with dose in-terruption. Prophylactic measures to promote good oral hygiene are recommended, including the use of a soft toothbrush that is changed on a regular basis; daily flossing; frequent rinsing with bland rinses such as sterile water, normal saline, or sodi-um bicarbonate. Avoidance of acidic, spicy, and hard or crunchy foods and alcoholic mouthwash are highly recommended. In ad-dition, close follow-up of patients after initiation of treatment with dose interruption and dosage reduction after resolution is important.32 In contrast to stomatitis associated with chemother-apy or radiation therapy, everolimus-induced stomatitis has an inflammatory component. The use of topical high-potency cor-ticosteroids (eg, dexamethasone 0.1 mg/mL; clobetasol gel 0.05 %), topical nonsteroidal anti-inflammatories (eg, amlexanox 5 % oral paste), and topical anesthetics (“miracle” or “magic” mouth-washes typically containing lidocaine viscous, diphenhydramine, and an antacid such as aluminum hydroxide or magnesium hy-droxide) are recommended.32,33

In clinical trials of PI3K inhibitors, common AEs included hy-perglycemia, GI toxicity, fatigue, transaminitis, and skin rash.19,22 Mood disorder was also seen in trials of buparlisib. Hypergly-cemia is an on-target side effect of PI3K inhibition, as a result of more sustained inhibition of p110a, and is often manageable with metformin.19,21,29 It remains to be determined whether iso-form-specific inhibitors are more advantageous in widening the therapeutic window of PI3K inhibitors.

Predictors of ResponseThe identification of genetic predictors of response to PI3K pathway inhibitors has been complicated by the presence of a multitude of genetic or epigenetic alterations of the pathway components and the lack of relevant tumor specimens.34 Sin-gle-gene alterations such as PIK3CA mutation have not been pre-dictive of treatment response in studies of everolimus and pan-PI3K inhibitors.19 In an effort to identify the target population of everolimus, archival tumor specimens from patients enrolled in the BOLERO-2 trial were subjected to targeted next-generation sequencing (NGS) of 182 cancer-related genes. No correlation with PFS was observed with each of the 9 genes with a mutation rate >10% (eg, PIK3CA, FGFR1, and CCND1), or when less fre-quently mutated genes (eg, PTEN, AKT1) were included in their respective pathways.34 However, most of the archival tumor spec-imens analyzed were obtained from the primary rather than the metastatic disease. Hypothetically, RNA or protein signatures that measure the signaling output of the PI3K pathway could be more informative. However, there is no established clinical assay for this approach at this time. Limited protein markers of PI3K pathway activity were evaluated in the translational study of TAMRAD, in which p4EBP1, LKB1, or PI3K protein expression were found to be predictive of everolimus benefit.35 Larger stud-



ies are needed to confirm the results. At this time, there are no established biomarkers available for patient selection.

Similarly, in clinical trials of pan-PI3K inhibitors, PIK3CA mutation or PTEN status has not been associated with the an-titumor response in clinical trials.19,21,22 Interestingly, in the neo-adjuvant pictilisib trial, luminal B cancers derived more benefit from the addition of pictilisib in Ki67 suppression.21 An explor-atory subgroup analysis in the FERGI trial demonstrated that addition of pictilisib to fulvestrant significantly improved PFS in the subgroup of patients with PR+ tumors.22 However, these results need to be validated in other trials. Perhaps isoform-spe-cific inhibitors are more likely to function in genetically defined populations based on their mechanisms of action.

Combination Treatment StrategiesThe antitumor activity of single-agent PI3K pathway inhibitors is likely limited due to the presence of feedback loops within the PI3K pathway and crosstalk between PI3K pathway and signaling pathways. Successful tumor control likely demands combination therapy approaches. Based on preclinical data, potential can-didate partners include inhibitors against RTKs, MEK, MYC, PARP, or the STAT3 pathway, and strategies to enhance auto-phagy and apoptosis (Table 2).18 Inhibition of the PI3K path-way leads to FOXO nuclear accumulation that upregulates the expression of RTK.36,37 Examples of ongoing clinical trials that target both the RTK and PI3K pathways include HER2-targeted agents in combination with PI3K inhibitors in HER2+ breast cancer.38 However, combining RTK inhibitors with PI3K path-way inhibitors may be challenging, as several RTKs could be up-regulated. An alternative approach is to combine PI3K pathway inhibitors with inhibitors of the RAS/RAF/MEK/ERK cascade, as both mediate RTK signaling and promote cell survival and proliferation. The extensive crosstalk between these 2 pathways has been demonstrated in preclinical studies. PI3K pathway in-hibition activates ERK,39 while MEK inhibition increases AKT activity.40 Clinical trials are ongoing to test the tolerability of this strategy.41 Data indicated increased toxicity with dual blockade of the PI3K and MEK pathways, but treatment could be particular-ly effective in tumors with genetic alterations in both pathways.42 Inhibitors of bromodomain and extraterminal domain (BET), which regulate the transcription level of MYC, may be reason-able approaches in tumors with MYC overexpression, as it has been shown to confer resistance to PI3K pathway inhibitors.43 BCL2 family proteins produce an antiapoptotic effect by main-taining mitochondrial integrity. Preclinical evidence supports the use of BCL2 antagonists, to prime for mitochondrial death, in combination with PI3K pathway inhibitors.44

ConclusionThe PI3K pathway is an important therapeutic target in breast cancer. In ER+ breast cancer, initial success has been observed

with mTOR inhibitors. In addition, clinical trials of mTOR ki-nase inhibitors and direct inhibitors of PI3K and AKT, which potentially inhibit the pathway more effectively, are ongoing. However, as single agents, the antitumor activity of PI3K pathway inhibitors is likely limited as a result of feedback regulation and crosstalk with RTK and other signaling pathways. Strategies that combine PI3K pathway inhibitors with inhibitors against RTKs, or inhibitors against MEK, MYC, PARP, or STAT3 pathways, or agents that activate autophagy and apoptosis machineries, are being explored. In addition, there is continued effort to identify resistance mechanisms and predictors of therapeutic response.

Affiliation: Cynthia X. Ma, MD, PhD, is associate professor of Medicine, Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO.Disclosure: Dr Ma reports receiving research funding from No-vartis, Pfizer, and Puma Biotechnology.Address correspondence to: Cynthia X. Ma, MD, PhD, As-sociate Professor of Medicine, Division of Oncology, Depart-ment of Medicine, Campus Box 8056, Washington Univer-sity School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110; phone: (314) 362-9383; fax: (314) 362-7086; email: [email protected].

REFERENCES1. Liu P, Cheng H, Roberts TM, Zhao JJ. Targeting the phos-phoinositide 3-kinase pathway in cancer. Nat Rev Drug Discov. 2009;8(8):627-644.2. Hirsch E, Ciraolo E, Franco I, et al. PI3K in cancer-stroma inter-actions: bad in seed and ugly in soil. Oncogene. 2014;33(24):3083-3090.3. Ma CX, Crowder RJ, Ellis MJ. Importance of PI3-kinase pathway in response/resistance to aromatase inhibitors. Steroids. 2011;76(8):750-752.

TablE 2. Potential Targets for Combination Therapy With PI3K Pathway Inhibitors

Target for Combination Therapy

Examples

Receptor tyrosine kinases HER2, EGFR, IGF-1R, FGFR

Estrogen receptor Hormonal therapy

MEK MEK inhibitor

MYC BET inhibitor

PARP PARP inhibitor

Autophagy Inducers of autophagy

BCL2 BCL2 inhibitor

STAT3 JAK2 inhibitor


· breast cancer ·

4. Network TCGA. Comprehensive molecular portraits of hu-man breast tumours. Nature. 2012;490(7418):61-70.5. Saal LH, Holm K, Maurer M, et al. PIK3CA mutations cor-relate with hormone receptors, node metastasis, and ERBB2, and are mutually exclusive with PTEN loss in human breast car-cinoma. Cancer Res. 2005;65(7):2554-2559.6. Zhang H, Liu G, Dziubinski M, et al. Comprehensive analysis of oncogenic effects of PIK3CA mutations in human mammary epithelial cells. Breast Cancer Res Treat. 2008;112(2):217-227.7. Zhao JJ. The oncogenic properties of mutant p110[agr] and p110[bgr] phosphatidylinositol 3-kinases in human mammary epithelial cells. Proc Natl Acad Sci. 2005;102:18443-18448.8. Crowder RJ, Phommaly C, Tao Y, et al. PIK3CA and PIK-3CB inhibition produce synthetic lethality when combined with estrogen deprivation in estrogen receptor-positive breast cancer. Cancer Res. 2009;69(9):3955-3962.9. Ellis MJ, Lin L, Crowder R, et al. Phosphatidyl-inositol-3-ki-nase alpha catalytic subunit mutation and response to neoad-juvant endocrine therapy for estrogen receptor positive breast cancer. Breast Cancer Res Treat. 2010;119(2):379-390.10. Miller TW, Hennessy BT, Gonzalez-Angulo AM, et al. Hy-peractivation of phosphatidylinositol-3 kinase promotes escape from hormone dependence in estrogen receptor-positive human breast cancer. J Clin Invest. 2010;120(7):2406-2413.11. Creighton CJ, Fu X, Hennessy BT, et al. Proteomic and tran-scriptomic profiling reveals a link between the PI3K pathway and lower estrogen-receptor (ER) levels and activity in ER+ breast cancer. Breast Cancer Res. 2010;12(3):R40.12. Sanchez CG, Ma CX, Crowder RJ, et al. Preclinical modeling of combined phosphatidylinositol-3-kinase inhibition with endo-crine therapy for estrogen receptor-positive breast cancer. Breast Cancer Res. 2011;13(2):R21.13. Bachelot T, Bourgier C, Cropet C, et al. Randomized phase II trial of everolimus in combination with tamoxifen in patients with hormone receptor-positive, human epidermal growth fac-tor receptor 2-negative metastatic breast cancer with prior ex-posure to aromatase inhibitors: a GINECO study. J Clin Oncol. 2012;30(22):2718-2724.14. Baselga J, Campone M, Piccart M, et al. Everolimus in post-menopausal hormone-receptor-positive advanced breast cancer. N Engl J Med. 2012;366(6):520-529.15. Piccart M, Hortobagyi GN, Campone M, et al. Everoli-mus plus exemestane for hormone-receptor-positive, human epidermal growth factor receptor-2-negative advanced breast cancer: overall survival results from BOLERO-2. Ann Oncol. 2014;25(12):2357-2362.16. O’Reilly KE, Rojo F, She QB, et al. mTOR inhibition induc-es upstream receptor tyrosine kinase signaling and activates Akt. Cancer Res. 2006;66(3):1500-1508.17. Massarweh S, Romond E, Black E, et al. A phase II study of combined fulvestrant and everolimus in patients with metastatic

estrogen receptor (ER)-positive breast cancer after aromatase in-hibitor (AI) failure. Breast Cancer Res Treat. 2014;143(2):325-332.18. Fruman DA, Rommel C. PI3K and cancer: lessons, challeng-es and opportunities. Nature Rev Drug Discov. 2014;13(2):140-156.19. Mayer IA, Abramson VG, Isakoff SJ, et al. Stand Up to Can-cer phase Ib study of pan-phosphoinositide-3-kinase inhibitor buparlisib with letrozole in estrogen receptor-positive/human epidermal growth factor receptor 2-negative metastatic breast cancer. J Clin Oncol. 2014;32(12):1202-1209.20. Ma CX, Luo J, Naughton M, et al. A phase I study of BKM120 and fulvestrant in postmenopausal women with estro-gen receptor positive metastatic breast cancer. Presented at: the 37th Annual San Antonio Breast Cancer Symposium; December 9-13, 2014; San Antonio, TX. Abstract PD5-6. 21. Schmid P, Pinder SE, Wheatley D, et al. Preoperative win-dow of opportunity study of the PI3K inhibitor pictilisib (GDC-0941) plus anastrozole vs anastrozole alone in patients with ER+, HER2-negative operable breast cancer (OPPORTUNE study). Presented at: the 37th Annual San Antonio Breast Cancer Sym-posium; December 9-13, 2014; San Antonio, TX. Abstract S2-03.22. Krop I, Johnston S, Mayer IA, et al. The FERGI phase II study of the PI3K inhibitor pictilisib (GDC-0941) plus fulves-trant vs fulvestrant plus placebo in patients with ER+, aromatase inhibitor (AI)-resistant advanced or metastatic breast cancer – part I results. Presented at: the 37th Annual San Antonio Breast Cancer Symposium; December 9-13, 2014; San Antonio, TX. Abstract S2-02.23. Rexer BN, Chanthaphaychith S, Dahlman K, Arteaga CL. Direct inhibition of PI3K in combination with dual HER2 in-hibitors is required for optimal antitumor activity in HER2+ breast cancer cells. Breast Cancer Res. 2014;16(1):R9.24. O’Regan R, Ozguroglu M, Andre F, et al. Phase III, random-ized, double-blind, placebo-controlled multicenter trial of daily everolimus plus weekly trastuzumab and vinorelbine in trastu-zumab-resistant, advanced breast cancer (BOLERO-3). J Clin Oncol. 2013;31(suppl; abstr 505).25. Hurvitz SA, Andre F, Jiang Z, et al. Phase 3, randomized, double-blind, placebo-controlled multicenter trial of daily evero-limus plus weekly trastuzumab and paclitaxel as first-line therapy in women with HER2+ advanced breast cancer: BOLERO-1. Pre-sented at: the 37th Annual San Antonio Breast Cancer Sympo-sium; December 9-13, 2014; San Antonio, TX. Abstract S6-01.26. Rexer BN, Arteaga CL. Optimal targeting of HER2-PI3K sig-naling in breast cancer: mechanistic insights and clinical implica-tions. Cancer Res. 2013;73(13):3817-3820.27. Saura C, Bendell J, Jerusalem G, et al. Phase Ib study of buparlisib plus trastuzumab in patients with HER2-positive ad-vanced or metastatic breast cancer that has progressed on tras-tuzumab-based therapy. Clin Cancer Res. 2014;20(7):1935-1945.28. Xu S, Li S, Guo Z, et al. Combined targeting of mTOR and AKT is an effective strategy for basal-like breast cancer in pa-



tient-derived xenograft models. Mol Cancer Ther. 2013;12(8):1665-1675.29. Bendell JC, Rodon J, Burris HA, et al. Phase I, dose-escala-tion study of BKM120, an oral pan-Class I PI3K inhibitor, in pa-tients with advanced solid tumors. J Clin Oncol. 2012;30(3):282-290.30. Ibrahim YH, Garcia-Garcia C, Serra V, et al. PI3K inhibition impairs BRCA1/2 expression and sensitizes BRCA-proficient triple-negative breast cancer to PARP inhibition. Cancer Discov. 2012;2(11):1036-1047.31. Juvekar A, Burga LN, Hu H, et al. Combining a PI3K in-hibitor with a PARP inhibitor provides an effective therapy for BRCA1-related breast cancer. Cancer Discov. 2012;2(11):1048-1063.32. Peterson ME. Management of adverse events in patients with hormone receptor-positive breast cancer treated with everolimus: observations from a phase III clinical trial. Support Care Cancer. 2013;21(8):2341-2349.33. Porta C, Osanto S, Ravaud A, et al. Management of adverse events associated with the use of everolimus in patients with ad-vanced renal cell carcinoma. Eur J Cancer. 2011;47(9):1287-1298.34. Hortobagyi GN, Piccart-Gebhart MJ, Rugo HS, et al. Cor-relation of molecular alterations with efficacy of everolimus in hormone receptor–positive, HER2-negative advanced breast can-cer: results from BOLERO-2. J Clin Oncol. 2013;31(suppl; abstr LBA509). 35. Treilleux I, Arnedos M, Cropet C, et al. Predictive markers of everolimus efficacy in hormone receptor positive (HR+) met-astatic breast cancer (MBC): final results of the TAMRAD trial translational study. J Clin Oncol. 2013;31(suppl; abstr 510).36. Chakrabarty A, Sanchez V, Kuba MG, et al. Feedback up-regulation of HER3 (ErbB3) expression and activity attenu-ates antitumor effect of PI3K inhibitors. Proc Natl Acad Sci. 2012;109(8):2718-2723.37. Rodrik-Outmezguine VS, Chandarlapaty S, Pagano NC, et al. mTOR kinase inhibition causes feedback-dependent biphasic regulation of AKT signaling. Cancer Discov. 2011;1(3):248-259.38. Singh JC, Jhaveri K, Esteva FJ. HER2-positive advanced breast cancer: optimizing patient outcomes and opportunities for drug development. Br J Cancer. 2014;111(10):1888-1898.39. Carracedo A, Ma L, Teruya-Feldstein J, et al. Inhibition of mTORC1 leads to MAPK pathway activation through a PI3K-dependent feedback loop in human cancer. J Clin Invest. 2008;118(9):3065-3074.40. Zmajkovicova K, Jesenberger V, Catalanotti F, et al. MEK1 is required for PTEN membrane recruitment, AKT regula-tion, and the maintenance of peripheral tolerance. Mol Cell. 2013;50(1):43-55.41. Saini KS, Loi S, de Azambuja E, et al. Targeting the PI3K/AKT/mTOR and Raf/MEK/ERK pathways in the treatment of breast cancer. Cancer Treat Rev. 2013;39(8):935-946.

42. Shimizu T, Tolcher AW, Papadopoulos KP, et al. The clinical effect of the dual-targeting strategy involving PI3K/AKT/mTOR and RAS/MEK/ERK pathways in patients with advanced can-cer. Clin Cancer Res. 2012;18(8):2316-2325.43. Ilic N, Utermark T, Widlund HR, Roberts TM. PI3K-tar-geted therapy can be evaded by gene amplification along the MYC-eukaryotic translation initiation factor 4E (eIF4E) axis. Proc Natl Acad Sci. 2011;108(37):E699-708.44. Rahmani M, Aust MM, Attkisson E, et al. Dual inhibition of Bcl-2 and Bcl-xL strikingly enhances PI3K inhibition-induced apoptosis in human myeloid leukemia cells through a GSK3- and Bim-dependent mechanism. Cancer Res. 2013;73(4):1340-1351.

30 www.ajho.com march 2015

· lung cancer ·

To Treat or Not to Treat: When Is adjuvant EGFr TKI Therapy appropriate?

ramsey asmar, mD, and Balazs halmos, mD

Introductionroughly 10% to 15% of lung adenocarcinomas diagnosed in the United States harbor activating mutations in the epidermal growth factor receptor (EGFR) gene.1 The remarkable efficacy of small-molecule EGFr tyrosine kinase inhibitors (TKIs) in this unique subset of patients has revolutionized the therapeutic ap-proach to lung cancer over the past 10 years, and has created a treatment paradigm for other molecularly defined subsets of cancer. multiple randomized phase 3 studies have demonstrated that EGFr TKIs are superior to chemotherapy in patients with stage IV EGFR-mutated disease, with excellent response rates (58%-75%) and, on average, a doubling of progression-free survival (PFS).2-5 Thus, agents such as erlotinib, gefitinib, or afa-tinib are now standard first-line therapy for advanced non-small cell lung carcinoma (NScLc) with sensitizing EGFR mutations. more recently, the second-generation EGFr TKI afatinib also has shown a significant overall survival (OS) benefit compared with first-line chemotherapy, specifically in patients with EGFR exon 19 deletion–positive tumors.6

The unprecedented success of these agents in the metastatic setting logically leads to the clinical question: are EGFr TKIs beneficial as adjuvant therapy for patients with earlier stages of disease? The importance of this question cannot be overstated. although early-stage lung cancers are treated surgically with

curative intent, recurrence rates after complete anatomic resec-tion remain unacceptably high, ranging from 30% to 70%.7 Tumor recurrence is in fact the primary obstacle to long-term survival. Only 36% to 73% of patients with stage Ia-IIB lung cancer are alive at 5 years; for those with stage III disease, the 2-year survival is less than 50% despite definitive therapy.8 We have learned that adjuvant/neoadjuvant cisplatin-based doublet chemotherapy can marginally improve survival by eradicating oc-cult micrometastases. The Lung adjuvant cisplatin Evaluation (LacE) trial,7 a pooled analysis of 5 large trials (4584 patients), demonstrated a 5-year OS benefit of 5.4% with chemotherapy. This is a fairly modest gain considering the toxicity associated with cisplatin-based chemotherapy, and leaves us in dire need of novel adjuvant approaches to improve cure rates.

Success in Other Tumor TypesThe use of molecularly targeted therapies in an adjuvant setting is not unprecedented, and there are lessons to be learned from successes in other tumor types. One example is imatinib mesylate therapy for resected gastrointestinal stromal tumors (GIST) that express constitutively activated mutant isoforms of KIT protein. In a landmark phase 3 trial of 770 patients, adjuvant imatinib demonstrated dramatically improved disease-free survival (DFS) compared with placebo for resected GIST (hazard ratio [hr] = 0.35; P <.0001).9 more recently, a randomized study showed im-proved OS in patients with GIST who received 3 (vs 1) years of adjuvant imatinib after resection, with survival curves remain-ing apart well past the point of TKI discontinuation.10 a second important example is adjuvant trastuzumab, which significantly improves OS after resection of HER2-positive breast cancer, with benefits that exceeded expectations based on its value in the met-astatic setting.11 These experiences provide compelling reasons to investigate the role of targeted agents in the adjuvant manage-ment of NScLc.

Early Clinical Trials of Adjuvant EGFR InhibitionThe earliest exploration of adjuvant EGFr inhibition involved 2 large randomized trials initiated over 10 years ago. although both were negative studies, it is important to recognize that nei-

Abstract

The use of epidermal growth factor receptor (EGFR) tyro-

sine kinase inhibitor (TKI) therapy in the adjuvant setting

for nonmetastatic EGFR-mutated lung cancer remains

controversial, as conclusive data to support this practice

are lacking. Recent prospective trials suggest an improve-

ment in disease-free survival with these agents; however,

an overall survival advantage is yet to be demonstrated.

Expedited adjuvant trials are sorely needed to determine

whether EGFR TKIs are beneficial for patients with earlier

stages of disease.

Key words: Lung cancer, EGFR, adjuvant

VOL. 11, NO. 3 ThE amErIcaN JOUrNaL OF hEmaTOLOGY/ONcOLOGY 31

to treat or not to treat: When Is adjuvant eGFr tKI therapy approprIate?

ther trial was enriched for patients with EGFR mutations. The first was SWOG S0023,12 a phase 3 study designed to enroll 672 patients with unresectable, locally advanced (stage III) NScLc receiving definitive chemoradiation. Patients whose disease did not progress after treatment were subsequently randomized to gefitinib 250 mg per day or placebo. however, an unplanned interim analysis (of 243 patients) in 2005 demonstrated an un-expectedly inferior survival for those receiving gefitinib (median of 23 vs 35 months; P = .013). The study was thus closed prema-turely, and routine use of maintenance EGFr TKIs in stage III disease is not currently recommended outside of a clinical trial.

The National cancer Institute of canada (NcIc) phase 3 Br.19 trial13 was the first randomized, double-blind, placebo-con-trolled investigation of a targeted agent (gefitinib) delivered in the adjuvant setting for completely resected NScLc. Patients with stage IB-IIIa NScLc were randomized, following surgical resection and optional adjuvant chemotherapy, to either 2 years of adjuvant gefitinib or placebo. Unfortunately, this study was also terminated early due to safety concerns based on the nega-tive phase 3, placebo-controlled ISEL trial14 that demonstrated no survival benefit with gefitinib as second- or third-line treat-ment for metastatic disease, as well as the aforementioned S0023 interim report.12 Thus, Br.19 accrued only 503 of the planned 1160 patients, and the median duration of study therapy was less than 5 months. Only 76 patients had EGFR-mutated disease (36 in the gefitinib arm, 40 in the placebo arm). an exploratory anal-ysis of this subgroup showed no difference in DFS (hr = 1.22; P =.15) or OS (hr = 1.24; P = .14), and a trend towards harm with gefitinib. In summary, Br.19 was underpowered, terminat-ed early, and nonenriched for the relevant population, and had suboptimal duration of therapy. It is thus impossible to draw sta-tistically robust conclusions from these data regarding the impact of adjuvant EGFr inhibition in early-stage NScLc.

Promising Recent Trial Dataalthough these initial studies were disappointing, more recently reported data offer promising insights. In 2011, investigators at memorial Sloan Kettering cancer center (mSKcc) retrospec-tively reviewed a prospectively maintained surgical database of 167 patients with resected stage I-III NScLc harboring EGFR exon 19 or 21 mutations.15 They compared 2 cohorts—one with 56 patients who received either adjuvant or neoadjuvant EGFr TKI therapy, and the other including 111 patients who did not receive TKI therapy. In the multivariate analysis, which con-trolled for stage and adjuvant platinum chemotherapy, the 2-year DFS was 89% for the TKI-treated cohort compared with 72% for the control group (hr = 0.53; P = .06). Importantly, however, there was no statistically significant difference in 2-year OS. The retrospective nature of this study introduces the possibility of sig-nificant bias, as treatment was primarily based on the preferences of patients and their oncologists. This highlights the crucial need

for prospective trials.The first prospective data to suggest that adjuvant targeted

therapy may indeed alter the disease course for early-stage NS-cLc were presented at the 2014 american Society of clinical Oncology (aScO) annual meeting, from the SELEcT and ra-DIaNT trials. The SELEcT trial16 was a multicenter, single-arm, phase 2 study of adjuvant erlotinib in resected, early-stage, EGFR mutation–positive NScLc. Patients with stage Ia-IIIa disease who completed routine adjuvant chemotherapy and/or radio-therapy subsequently received erlotinib 150 mg daily for 2 years, followed by computed tomography (cT) surveillance. The inves-tigators reported a 2-year DFS of 89%, an improvement over the historical control of 76% that was used to power the study. While this is an encouraging result, a considerable drop-off in DFS was seen by 3 years among these highly selected patients, and with the absence of a comparator arm, conclusions cannot be reached regarding true benefit. Of note, the majority of recurrences (25 of 29) were seen after erlotinib discontinuation, raising import-ant questions about the optimal duration of TKI therapy.

also reported at aScO 2014 were the results of raDIaNT,17 a phase 3 study investigating adjuvant erlotinib in patients with resected NScLc with overexpression of EGFr protein by immu-nohistochemistry (Ihc) or EGFR gene amplification by fluores-cence in situ hybridization (FISh). These 2 selection biomarkers are no longer considered to be of significant value, and only 16.4% of enrolled patients had tumors with activating EGFR mutations. after complete resection (stage IB-IIIa) and optional adjuvant chemotherapy, patients were randomized (2:1) to re-ceive either erlotinib 150 mg daily or placebo for 2 years. Posthoc subset analysis of the EGFR-mutated population (161 patients; 102 erlotinib, 59 placebo) favored erlotinib, with a median DFS of 46.4 months compared with 28.5 months with placebo (hr = 0.61; P = .0391, though not statistically significant due to hi-erarchical testing).18 The OS data remain immature, with only 22% of necessary events having occurred, and the median was thus not reached. raDIaNT highlights some of the pitfalls of a posthoc analysis using a biomarker for which the study was not stratified, raising concerns about statistical power and validity as well as potential confounders. For example, among the patients with EGFR mutations, 30.5% in the placebo arm had stage IIIa disease compared with only 17.6% in the erlotinib arm. Because most stage III patients will recur, this major imbalance likely bi-ases the results in favor of adjuvant therapy.

additional prospective data come from a recently published, small, randomized phase 2 chinese study investigating patients with resected stage IIIa (N2) NScLc harboring EGFR mutations (exon 19 deletions or L858R point mutations).19 Sixty patients were enrolled and received adjuvant carboplatin/pemetrexed chemotherapy, then were randomized to either gefitinib 250 mg daily for 6 months or observation. The primary endpoint was DFS, and the study was powered to show a 20% improvement


· lung cancer ·

after 2 years. The results were quite impressive, with a median DFS of 40 months in the gefitinib arm compared with only 27 months with placebo (hr = 0.37; P = .014). The 2-year OS was 92% versus 77%, favoring gefitinib (hr = 0.37; P = .076), al-though the survival data remain premature, and this small study was not powered to show OS benefit.

No Improvement in OSDespite these strides forward, none of the adjuvant studies de-scribed in Table 1 indicate an improvement in OS—the key mea-sure that must be demonstrated for any adjuvant therapy. This leaves us asking a crucial question: Do EGFr TKIs truly elim-

inate micrometastases (thereby curing the patient), or do they merely suppress minimal residual disease for a period of time? If the latter is true, one could perhaps argue in favor of reserving the targeted agent until the time of relapse, when it could then be offered as rescue therapy.

In fact, a long-standing concern about adjuvant EGFr inhi-bition is the notion that exposure to erlotinib or gefitinib may alter the tumor’s biology, rendering it resistant at the time of recurrence (via a secondary mutation such as T790M, or through other mechanisms). This concern was discussed in a small yet thought-provoking 2011 retrospective mSKcc study in which 22 patients with disease recurrence after adjuvant EGFr TKI

Table. Summary of Adjuvant Studies of EGFR TKI Therapy in Lung Cancer

DFS indicates disease-free survival; EGFR+, epidermal growth factor receptor mutation–positive; FISH, fluorescence in situ hybridization; HR, hazard ratio; IHC, immunohistochemistry; NCIC, National Cancer Institute of Canada; NS, not significant; OS, overall survival; PFS, progression-free survival; TKI, tyrosine kinase inhibitor.

Study No. ofPatients

Stage biomarker adjuvant Regimen

Prior DefinitiveTreatment

OS DFS or PFS

SWOG S002312 243 (of a planned 672)

IIIA – IIIB Unselected Gefitinib vs placebo for 5 years

Concurrent chemoradiation

Gefitinib arm inferior (P = .013)

NS, trend toward harm in gefitinib arm for PFS (HR = .08; P = .17)

NCIC BR.1913 503 (of a planned 1160)

IB – IIIA Unselected Gefitinib vs placebo for 2 years

Resection +/- adjuvant chemotherapy

NS, trend toward harm in gefitinib arm(EGFR+ subset)

NS, trend toward harm in gefitinib arm(EGFR + subset)

MSKCC retrospective15

167 I – III EGFR exon 19 or 21 mutation

Erlotinib/gefitinib (adjuvant or neoadju-vant) vs no TKI


NS TKI superior(HR = 0.53; P = .06)

SELECT16 100 IA – IIIA Sensitiz-ing EGFR mutation

Erlotinib for 2 years (single-arm)

Resection + standard chemo- and/or radiotherapy

Data not mature

Erlotinib superior for 2-year DFS (89% vs 76% for historical control)

RADIANT17,18 973 total (161 EGFR+)

IB – IIIA EGFR+ by IHC or FISH

Erlotinib vs placebo for 2 years


NS Erlotinib arm su-perior in posthoc EGFR+ subset (HR = 0.61; P = .0391)(NS due to hierar-chical testing)

Chinese randomizedphase 2 study19

60 IIIA (N2) EGFR exon 19 del or exon 21 L858R point muta-tion

Carboplatin/ pemetrexed +/- gefitinib for 6 months

Resection Gefitinib arm favored, though un-derpowered and data not mature(HR = 0.37; P = .076)

Gefitinib arm superior(HR = 0.37; P = .014)

VOL. 11, NO. 3 ThE amErIcaN JOUrNaL OF hEmaTOLOGY/ONcOLOGY 33

to treat or not to treat: When Is adjuvant eGFr tKI therapy approprIate?

therapy were identified.20 Eleven of these patients were retreated, and 8 of the 11 responded for a median duration of 10 months. Furthermore, repeat biopsies revealed the T790M resistance mu-tation only in patients on active therapy—those who had already completed adjuvant TKI therapy did not have tumor genotypes with secondary resistance mutations. This suggests that retreat-ment with erlotinib/gefitinib at the time of recurrence is feasi-ble, and implies that longer durations of adjuvant therapy may be necessary.

Questions Remainmany other unanswered questions remain. First, exactly which “early-stage” patients should qualify for adjuvant EGFr inhibi-tion? much like with adjuvant chemotherapy, the benefit derived from a TKI will be relative to the absolute risk of disease recur-rence, and is thus expected to be less for those with lower stages of disease. With this basic principle in mind, an oncologist may be more inclined to offer adjuvant TKIs to patients with high-risk stage III disease than to those with relatively low-risk stage I disease. caution must be exercised in this regard, however. as previously discussed, the SWOG S0023 experience showed that gefitinib was actually harmful after definitive chemoradiation for locally advanced disease.12 Ultimately, we lack the data necessary to construct sound treatment guidelines based on relative risk.

Second, what is the optimal duration of adjuvant TKI therapy? most recurrences in the SELEcT and raDIaNT trials occurred after discontinuation of erlotinib.16,17 although this may suggest a need for more than 2 years of treatment, the aforementioned chinese adjuvant study demonstrated positive results with only 6 months of adjuvant gefitinib.19 an ongoing clinical trial using afatinib (NcT01746251) is evaluating 3 versus 24 months of ad-juvant therapy for resected stages I-III NScLc in an effort to determine whether prolonged treatment courses are superior to shorter ones.

Third, adverse events associated with chronic EGFr TKI ther-apy must also be considered. although these agents are generally well tolerated, the side effects are certainly not negligible; rash and diarrhea (each occur in 50% of cases) can have significant impact on quality of life for some, and well-informed decisions must be made before exposing patients to these potential risks.

Finally, the cost of therapy remains a key issue. a 2-year course of erlotinib costs approximately $150,000, and there are rough-ly 10,000 EGFR-mutated lung cancer resections per year in the United States alone. If all these patients were to receive adjuvant erlotinib, it would amount to a staggering $1.5 billion healthcare cost. a conclusive demonstration of clinical benefit is necessary before committing to such an expenditure in the affordable care act era.

Phase 3 Trials NeededThe data from raDIaNT and SELEcT suggest that adjuvant

TKI therapy may offer a consistent and significant reduction in the risk of early recurrence for patients with EGFR-mutated disease, potentially improving upon adjuvant chemotherapy. however, as encouraging as this may seem, the data are far from conclusive, and phase 3 prospective trials remain necessary. Sev-eral such studies are under way, the most pivotal being the aL-chEmIST study, a suite of integrated precision medicine trials that aim to provide definitive answers. Powered for OS, aLchE-mIST will compare 2 years of adjuvant TKI versus placebo thera-py for resected, early-stage lung adenocarcinoma, using erlotinib for EGFR-mutated or crizotinib for ALK-translocated disease. a trial of this importance should have already been completed by now. as it now stands, mature data will not be available for an-other 10 years—an unacceptably long time to wait.

In the meantime, our focus is quickly shifting to the more specific third-generation EGFr TKIs—agents in development such as aZD9291 and cO-1686—that have shown higher efficacy, more favorable side-effect profiles, and activity in advanced T790m mutation-bearing disease. These inhibitors will almost certainly be available for mainstream use well ahead of the fi-nal data analysis from aLchEmIST. To this end, a randomized study comparing aZD9291 with placebo in the adjuvant setting is planned. We strongly support early initiation of such critical adjuvant trials with newer agents in an effort to answer this ques-tion in a far timelier manner. Only then can we take the next steps forward to continue improving cure rates for our patients with this deadly disease—namely, to determine whether EGFr inhibition can replace chemotherapy altogether in the adjuvant space, and to investigate targeted and immunotherapy combina-tion approaches.

ConclusionWhile adjuvant EGFr TKI therapy may ultimately prove to be beneficial, current data supporting its use remain limited and an OS advantage has not yet been demonstrated. Nonetheless, molecular testing for EGFR (and ALK) gene mutations should be seriously considered in patients with resected lung adenocar-cinomas so that appropriate patients can be offered enrollment in ongoing adjuvant trials whenever possible. Outside of clinical studies, we must have informed and balanced discussions with our patients with EGFR-mutated NScLc regarding adjuvant TKI therapy, carefully weighing the pros and cons in light of the currently limited available data.

Affiliations: ramsey asmar, mD, is a fellow in hematology and Oncology, and Balazs halmos, mD, is associate professor of med-icine at columbia University medical center, New York-Presby-terian hospital, New York, NY.Disclosures: Dr halmos has received clinical research funding from astellas, Genentech/roche, astraZeneca, and Boehringer Ingelheim, and has performed consulting for Genentech/roche,


· lung cancer ·

astraZeneca, clovis, and Boehringer Ingelheim. Dr asmar re-ports no relevant conflicts of interest to disclose. Address correspondence to: Balazs halmos, mD, Divi-sion of hematology/Oncology, columbia University medi-cal center, 161 Fort Washington ave, 9th Floor, New York, NY 10032; phone: 212-305-3997; fax: 646-317-6321; email: [email protected].

REFERENCES1. Zhang Z, Stiegler aL, Boggon TJ, Kobayashi S, halmos B. EGFr-mutated lung cancer: a paradigm of molecular oncology. Oncotarget. 2010;1(7):497-514.2. maemondo m, Inoue a, Kobayashi K, et al. Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFr. N Engl J Med. 2010;362(25):2380-2388.3. mitsudomi T, morita S, Yatabe Y, et al. Gefitinib versus cisplatin plus docetaxel in patients with non-small-cell lung cancer harbouring mutations of the epidermal growth factor receptor (WJTOG3405): an open label, randomised phase 3 trial. Lancet Oncol. 2010;11(2):121-128.4. mok TS, Wu YL, Thongprasert S, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med. 2009;361(10):947-957.5. rosell r, carcereny E, Gervais r, et al. Erlotinib versus standard chemotherapy as first-line treatment for European patients with advanced EGFr mutation-positive non-small-cell lung cancer (EUrTac): a multicentre, open-label, randomised phase 3 trial. Lancet Oncol. 2012;13(3):239-246.6. Yang Jc, Wu YL, Schuler m, et al. afatinib versus cisplatin-based chemotherapy for EGFr mutation-positive lung adenocarcinoma (LUX-Lung 3 and LUX-Lung 6): analysis of overall survival data from two randomised, phase 3 trials. Lancet Oncol. 2015;16(2):141-151.7. Pignon JP, Tribodet h, Scagliotti GV, et al. Lung adjuvant cisplatin evaluation: a pooled analysis by the LacE collaborative Group. J Clin Oncol. 2008;26(21):3552-3559.8. Goldstraw P, crowley J, chansky K, et al. The IaSLc Lung cancer Staging Project: proposals for the revision of the TNm stage groupings in the forthcoming (seventh) edition of the TNm classification of malignant tumours. J Thorac Oncol. 2007;2(8):706-714.9. Dematteo rP, Ballman KV, antonescu cr, et al. adjuvant imatinib mesylate after resection of localised, primary gastrointestinal stromal tumour: a randomised, double-blind, placebo-controlled trial. Lancet. 2009;373(9669):1097-1104.10. Joensuu h, Eriksson m, Sundby hall K, et al. One vs three years of adjuvant imatinib for operable gastrointestinal stromal tumor: a randomized trial. JAMA. 2012;307(12):1265-1272.11. Smith I, Procter m, Gelber rD, et al. 2-year follow-up of trastuzumab after adjuvant chemotherapy in hEr2-

positive breast cancer: a randomised controlled trial. Lancet. 2007;369(9555):29-36.12. Kelly K, chansky K, Gaspar LE, et al. Phase III trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage III non-small-cell lung cancer: SWOG S0023. J Clin Oncol. 2008;26(15):2450-2456.13. Goss GD, O’callaghan c, Lorimer I, et al. Gefitinib versus placebo in completely resected non-small-cell lung cancer: results of the NcIc cTG Br.19 study. J Clin Oncol. 2013;31(27):3320-3326.14. Thatcher N, chang a, Parikh P, et al. Gefitinib plus best supportive care in previously treated patients with refractory advanced non-small-cell lung cancer: results from a randomised, placebo-controlled, multicentre study (Iressa Survival Evaluation in Lung cancer). Lancet. 2005;366(9496):1527-1537.15. Janjigian YY, Park BJ, Zakowski mF, et al. Impact on disease-free survival of adjuvant erlotinib or gefitinib in patients with resected lung adenocarcinomas that harbor EGFr mutations. J Thorac Oncol. 2011;6(3):569-575.16. Pennell Na, Neal JW, chaft JE, et al. SELEcT: a multicenter phase II trial of adjuvant erlotinib in resected early-stage EGFr mutation-positive NScLc. J Clin Oncol. 2014;32(15 suppl; abstr 7514).17. Kelly K, altorki NK, Eberhardt WEE, et al. a randomized, double-blind phase 3 trial of adjuvant erlotinib (E) versus placebo (P) following complete tumor resection with or without adjuvant chemotherapy in patients (pts) with stage IB-IIIa EGFr positive (Ihc/FISh) non-small cell lung cancer (NScLc): raDIaNT results. J Clin Oncol. 2014;32(15 suppl; abstr 7501).18. Shepherd Fa, altorki NK, Eberhardt WEE, et al. adjuvant erlotinib (E) versus placebo (P) in non-small cell lung cancer (NScLc) patients (pts) with tumors carrying EGFr-sensitizing mutations from the raDIaNT trial. J Clin Oncol. 2014;32(15 suppl; abstr 7513).19. Li N, Ou W, Ye X, et al. Pemetrexed-carboplatin adjuvant chemotherapy with or without gefitinib in resected stage IIIa-N2 non-small cell lung cancer harbouring EGFr mutations: a randomized, phase II study. Ann Surg Oncol. 2014;21(6):2091-2096.20. Oxnard Gr, Janjigian YY, arcila mE, et al. maintained sensitivity to EGFr tyrosine kinase inhibitors in EGFr-mutant lung cancer recurring after adjuvant erlotinib or gefitinib. Clin Cancer Res. 2011;17(19):6322-6328.

iNSTRUCTiONS FOR AUTHORS

The rapid pace of discovery in the field of oncology presents practicing oncologists with the difficult challenge of implementing novel research findings into clinical practice. In order to accelerate the translation of academic advances to community-based practice, The American Journal of Hematology/Oncology aims to provide practical interpretations of the latest advances in medical and hematologic oncology and to help practicing oncologists gain a better understanding of how these advances have changed the treatment landscape for both solid and hematologic malignancies. The editors are pleased to consider manuscripts on a wide range of topics related to the journal’s mission. Articles of interest include:• Original research• Reviews

- State of the Art Updates- On the Horizon- Emerging Guidelines

• Editorials and perspectives- Clinical Controversies - Looking Forward- Brief Reports- Pivotal Trials- New Technologies- Meeting Updates - Case Reports- Survivorship Issues- Team Approaches (Allied Health/Care Extenders)

- Pharmacology Updates- Oncology Practice Issues: Evolving

Detailed descriptions of each category can be found in the Instructions for Authors at www.ajho.com.

T h e

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F o f

LYMPHOMAThe Role of PET Imaging in the Management of Patients With Hodgkin Lymphoma Craig Moskowitz, MD

LEUKEMIAA Primer on Molecular Testing in Chronic Myeloid Leukemia (PCR for Poets)Jerald P. Radich, MD

OVARIAN CANCERGenomic (“Precision”) Medicine in the Management of Ovarian CancerMaurie Markman, MD PER: 9TH ANNUAL INTERNATIONAL SYMPOSIUM ON OVARIAN CANCER AND GYNECOLOGIC MALIGNANCIES®

What Would Clinicians Do If BRCA or Lynch Positive?Medical Management, Insurance Discrimination, and Confidentiality

A m e r i c a n

J o u r n a l

H e m a t o l o g y /

O n c o l o g y ®

A Peer-Reviewed Resource

for Oncology Education

CMEMedical Crossfire: Recent Advances in the Treatment of Metastatic Melanoma A CME-certified enduring material sponsored by Physicians’ Education Resource®, LLC

ajho

www.AJHO.com

All manuscripts will undergo peer review, and authors of accepted articles will receive an honorarium and will be required to sign an authorship form disclosing any possible conflicts of interest. To submit an article to The American Journal of Hematology/Oncology or if you wish to speak to an editor, please e-mail Devera Pine at [email protected].

Call for Papers

AJHO_CallForPapers_08'14.indd 5 10/7/14 10:53 AM



Mission & Scope The American Journal of Hematology/Oncology is a monthly, peer-reviewed publication that provides original research, reviews, and editorials/commentaries that address cutting-edge developments in genomics, targeted therapies, molecular diagnostics, and pathways related to oncological science and clinical practice. As the official publication of Physicians’ Education Resource (PER), the journal’s mission is to advance cancer care through professional education. The journal aims to provide practical interpretations of the latest advances in medical and hematologic oncology and to help practicing oncologists gain a better understanding of how these advances are changing the treatment landscape for both solid and hematologic malignancies. Articles published in the journal will illustrate successes and failures in clinical practice and provide prac-tical insights into the myriad decisions oncologists face in everyday clinical practice. Readership: The American Journal of Hematology/Oncology circulates to 10,000 practicing oncologists across the country. Our audience includes medical oncologists, hematologists, pathologists, dermatologists, radiation oncologists, and surgical oncologists. Submitting Manuscripts Requirements for all submissions generally conform to the “Uni-form Requirements for Manuscripts Submitted to Biomedical Journals.”1 Our peer review process is blinded, so all identifying information (ie, author names, affiliations, etc) must be removed from the manuscript file before submission. Manuscripts submitted for publication in The American Journal of Hematology/Oncology must not have been published previously (either in whole or in part) nor currently be submitted elsewhere in either identical or similar form. Material posted on the Internet

or disseminated in any other electronic form constitutes prior publication and may not be considered. Previous publication of a small portion of the content of a manuscript does not necessarily preclude its being published in The American Journal of Hematology/Oncology, but the editors need information about previous publica-tion when deciding how to use space in the journal efficiently.

These restrictions on prior publication, however, do not apply to abstracts or poster presentations published in connection with scientific meetings or to working papers that have been posted on the Web to facilitate peer feedback.

Authors must indicate in the cover letter whether any portion of the manuscript has been previously published and are required to submit copies of related publications (either published, in prepara-tion, or submitted), as well as any manuscripts cited as “in press” to the editors for review. Duplicate, redundant, and/or fragmented publications are not permitted. Refer to Chapter 5 of the American Medical Association (AMA) Manual of Style for further information on duplicate publication.2 Authors should also include a statement in the body of the paper that indicates whether the study was approved by an institutional review board. For all papers (when appropriate), a statement confirming that the informed consent of study subjects was obtained should be included in the manuscript.

Articles of Interest The editors are pleased to consider manuscripts on a wide range of topics related to the Journal’s mission. Authors should write for a sophisticated general audience and recognize that many of The American Journal of Hematology/Oncology readers are not researchers. In addition to evaluating articles for scientific merit, the editors will also assess the overall relevance of the work to the journal’s audience.

If you are uncertain of an article’s appropriateness for The American Journal of Hematology/Oncology, we encourage authors to

iNSTRUCTiONS FOR AUTHORSiNSTRUCTiONS FOR AUTHORS


send an abstract or outline of an article to the Editorial Office ([email protected]) to facilitate a pre-submission review with the Editor-in-Chief.

Submissions generally fall into one of the following categories: (1) original research; (2) reviews; or (3) editorials or perspectives.

Original research articles should employ a clear hypothesis-driven research question and an appropriate research design and analysis to report clinically relevant outcomes. Articles should be 2000-2500 words (excluding abstract, references, tables, etc) and contain no more than 5 graphic elements. Supplemental data (extra tables, fig-ures, or appendices) will be made available on the journal’s website at the time of publication. Authors should indicate what material is intended as Web-only content and include the appropriate refer-ence or callout in the text to these Web-exclusive elements.Reviews should provide concise, up-to-date reviews of novel therapies and treatment strategies or other clinically relevant over-views. Authors should present real-world examples and discussion of the inherent challenges of incorporating new therapeutics, new treatment strategies, and new diagnostic tools into clinical practice. Articles should be 1500 to 2000 words with at least 1 graphic ele-ment to illustrate a key concept. The journal’s graphic design staff is available to develop original figures based on a sketch provided by authors. Types of review articles are as follows:• State-of-the-Art Update: Reviews of the evidence support-

ing recent key developments in the treatment of cancer, with a particular focus on information essential and applicable to clinical practice. Please illustrate key points with tables and/or figures (assistance is available from the journal staff for the development of figures).

• On the Horizon: Reviews of translational research, therapies, and technology that are in development but that clinicians will need to be aware of within the next few years. If applicable, please illustrate key points with figures (assistance is available from the journal staff) and provide relevant citations.

• Emerging Guidelines: Highlights of the key points of the most recent clinical practice guidelines, with expert perspec-tives/opinions on the changes to the guidelines. This can be 1000 words or less, without a figure.

Editorials and perspectives can employ several formats that provide concise and lively discussions on timely and relevant topics. These would typically involve areas of rapid change, controversy, or new areas that have the potential for major future clinical impact in oncology. These should be brief (less than 1500 words) with appropriate citations. Examples include:• Clinical Controversies: Opinion pieces that discuss relevant

and controversial issues in oncology (eg, maintenance ritux-imab and its role in indolent lymphoma, should DCIS be considered a cancer, when to intervene or start chemotherapy in prostate cancer, what is the quality of life impact of PFS

vs OS improvements, etc). In some cases, two authors would contribute opposing but coordinated (pro/con, or point/counterpoint) pieces.

• Looking Forward: New areas of research or clinical care that are not well known to many oncologists, but may in the future impact cancer care or research directions. This perspective would be a “thought piece” without significant amounts of data or citations.

• Brief Reports: Brief and topical perspectives and updates on new concepts, treatments, and diagnostic assays (less than 1000 words)

• Pivotal Trials: Summaries of clinical trials of interest. Should include the background/rationale, eligibility, treatment sche-ma, contact information, and NCT link (up to 1000 words)

• New Technologies: Discussions of imaging and tissue-based technologies, genomics, bioinformatics, etc (up to 1000 words)

• Meeting Updates: Summaries of presentations at key CME meetings, conferences, and congresses, with expert perspec-tives on the reported findings (please query the editorial team first to avoid duplication of coverage of meetings)

• Case Reports: Unusual cases, situations, exceptional respond-ers, including histology and imaging

• Survivorship: Discussions of survivorship topics and symp-tom management (1000-1500 words)

• Allied Health/Care Extenders: Discussions of how to best use a team approach; this can be a case report format—eg, discussion of how an individual team met and overcame a challenge or streamlined a process to improve patient care using allied health professionals/care extenders (1000-1500 words). The journal’s editors encourage allied health profes-sionals on the oncology care team to author or co-author these articles

• Pharmacology Updates: Brief overview of new drugs—mechanisms, dosing, side effects, drug interactions (1000-1500 words). These could be contributed by a pharmacist or a PharmD and may have the look of a write-up typical of a Pharmacy & Therapeutics Committee formulary application.

• Oncology Practice Issues: Evolving aspects of oncology practice such as insurance coverage, electronic medical re-cords, quality assurance, accelerated drug approvals, survivor-ship, and patient education/communication that present new perspectives and useful information to oncologists (1000-1500 words)

Authorship Only persons who have made a direct contribution to the content of a paper should be listed as authors. The number of authors listed with the manuscript should not exceed 10; more than 10 requires written justification and approval from the Editor-in-Chief.

The American Journal of Hematology/Oncology uses the criteria provided by the “Uniform Requirements for Manuscripts Submit-



ted to Biomedical Journals”1 to determine authorship. Each author should have participated sufficiently in the work to take public responsibility for the content. Authorship credit should be based only on substantial contributions to (a) conception and design, or analysis and interpretation of data; and to (b) drafting the article or revising it critically for important intellectual content; and on (c) final approval of the version to be published. Conditions (a), (b), and (c) must all be met.1

Individuals who have contributed to a paper but who do not meet the criteria for authorship should be acknowledged. Disclosures It is our policy to have all authors disclose relationships with any commercial interest that may present a real or perceived conflict of interest if: (a) the relationship is financial and occurred within the past 12 months; and (b) the author discusses products or ser-vices of that commercial interest. Relevant financial relationships are those relationships in which the author (and/or the author’s spouse or partner) benefits in any dollar amount by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (eg, stocks, stock options, or other ownership interests, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles, such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board mem-bership, and/or other activities for which remuneration is received or expected. In addition, authors are required to report all financial and material support for their research, which includes (but is not limited to) grant support and funding sources and any provision of equipment or supplies. To this end, all authors must read and sign the journal’s Author Disclosure Form.

The name of the organization funding or initiating a research project should be made explicit on the title page (eg, “This study was funded by the XYZ Corporation.”). Relevant financial relation-ships (whether direct to the authors or through a third party) for research and/or writing, including funding, grants, honoraria, etc, must also be named on the title page. If the funding organization had any role in the collection of data, its analysis and interpreta-tion, and/or in the right to approve or disapprove publication of the finished manuscript, this must be noted in the cover letter and described in the text. The editorial staff may inquire further about financial disclosure after the manuscript is submitted. If the manuscript is accepted for publication, disclosure statements will be printed as part of the published paper. ManuscriptSpecifications Manuscript components (cover letter, text, tables, figures, related papers, etc) must be included as part of the submission process. All manuscripts should include the following components:Cover Letter: A cover letter must accompany each submission and

include any background information about the submission (ie, how it contributes to the existing literature, whether any portion has been previously presented or published, etc) that would aid in the editors’ initial evaluation. Include a statement that the manuscript has been read and approved by all authors.Titles. Titles should be concise (fewer than 10 words) and stimu-late reader interest. Provide a brief running title in addition to the main article title.

The title page should include the following information:• the complete manuscript title and subtitle, if any• the full names of each author, followed by their highest aca-

demic degree• the name, address, telephone, fax, and e-mail information of

the corresponding author• the institutional affiliations for each author at the time the

work was completed• a concise summary of the article to appear in the table of

contents (no more than 25 words) • practical application of your work (a bulleted list that high-

lights the real-world impact of your work)• indication of the source of funding (including grant numbers,

grant agencies, corporations, or sponsors)• the number of pages, references, figures, and tables• a word count (excluding references, tables, and figures)

Abstract. An abstract is required for all manuscript submissions. The abstract should not exceed 250 words and should summarize the salient data and the principal conclusion of the piece.

Text. All text should be double-spaced, including the acknowledg-ments, references, tables, and legends. Cite references, tables, and figures in sequential order in the body of the paper. Measurements of length, height, weight, and volume should be reported in metric units. Temperatures should be given in degrees Celsius. Blood pres-sures should be listed in millimeters of mercury. Except for units of measure, abbreviations are discouraged.

Any abbreviation or acronym must be spelled out in full when it first appears in the text, followed by its abbreviation in parentheses. State the generic name (not the trade name) for all drugs.

Permissions: Data and/or figures reproduced from another pub-lished source must be properly cited and acknowledged. Authors are required to obtain written permission from the appropriate author and/or copyright holder to reproduce previously published or copyrighted material. Authors must also obtain permission from at least 1 author when citing unpublished data, “in-press” articles, and/or personal communications. Copies of permission statements should be included with manuscript submissions.

Acknowledgments. Include a list of acknowledgments, if ap-propriate. Refer to the “Authorship” section for an explanation

iNSTRUCTiONS FOR AUTHORSiNSTRUCTiONS FOR AUTHORS


of what constitutes authorship and for guidance in distinguishing contributions that warrant an acknowledgment. The corresponding author must affirm that he/she has received permission to list the individuals in the acknowledgment section (see bottom of Author-ship Form).

References. Begin the reference section on a new page and double-space both within and between reference citations. Number references sequentially in the order cited in the text—do not alphabetize. Provide the names of all authors when there are six or fewer; if there are more than six authors, list only the first three authors followed by “et al.” All references must be verified by the authors and should conform to the AMA Manual of Style.2

References cited only in table or figure legends should be numbered in accordance with the sequence established by the first mention of the particular table or figure in the text.

References to papers accepted but not yet published should be designated as “in press” and included in the reference section. Information from manuscripts submitted but not accepted should be cited in the text as “unpublished observations” with written permission from the source. (Include copies of any “in press” and “submitted” manuscripts [ie, papers under consideration at other journals] for the editors’ evaluation as part of your submission.)

Avoid citing “personal communication” unless it provides es-sential information not available from a public source, in which case the name of the person, his or her degree, and the date of communication should be cited in parentheses in the text. Authors should obtain written permission and confirmation of accuracy from the source of a personal communication (see “Permissions” section). Note the format and punctuation in the following sample references:1. Cortes JE, Kim DW, Kantarjian HM, et al. Bosutinib versus imatinib in newly diagnosed chronic-phase chronic myeloid leuke-mia: results from the BELA trial [published online September 4, 2012]. J Clin Oncol. 2012;30(28):3486-3492.2. Wierda WG, O’Brien S. Chronic lymphoblastic leukemia. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology, 9th ed. Phila-delphia: Lippincott Williams & Wilkins; 2011.3. American Cancer Society. Cancer Facts and Figures 2012. http://www.cancer.org/acs/groups/content/@epidemiology-surveilance/documents/document/acspc-031941.pdf Accessed October 5, 2012.

Graphic Elements. Use of graphic elements is strongly encour-aged, and The American Journal of Hematology/Oncology will print up to 5 graphic elements. All supplemental data (eg, appendices and lengthy tables) will be posted on the journal’s website at the time of publication. Authors should indicate what material is intended for web-exclusive content and include the appropriate reference or callout in the text to these web-exclusive elements.

Tables. Place each table on a new page. Number tables sequen-tially in the order they are cited in the text. Include a title for each table. Special characters, abbreviations, and symbols must be explained in a footnote to the table.

Figures. The journal’s production team is available to create figures from sketches provided by the authors. Avoid the use of shading in bar graphs or pie charts—use color or crosshatch pat-terns instead. Number all figures in the order they are mentioned in the text. Any previously published figures must be accompa-nied by written permission from the publisher and/or copyright holder (see “Permissions” section).

Legends. Legends should be double-spaced and include the figure number and a brief description of the illustration. Identify all abbreviations used in the figure at the end of each legend.

Peer Review Each manuscript is sent to the Editor-in-Chief for an internal evaluation to determine its appropriateness. Manuscripts that do not meet the journal’s criteria for overall appropriateness, relevance, originality, and scientific merit will be returned promptly (usually within 2 weeks) so that authors may pursue alternate avenues for publication. Although reviewer selection is ultimately the decision of the edi-tors, authors may provide the names and e-mail information of preferred and nonpreferred peer reviewers. Manuscripts deemed appropriate for The American Journal of Hematology/Oncology will be sent to external peer reviewers. Typically, a manuscript will be sent to a minimum of two reviewers who will be asked to provide feedback on the scientific merit of the paper. The Editorial Office contacts reviewers in advance and asks them to complete their evaluation of a manuscript within two weeks. Re-viewers are asked to treat manuscripts as confidential communica-tions and not to share their content with anyone (except colleagues whom they ask in confidence to assist in reviewing) or to use the content for their own purposes. We do not send a manuscript to a reviewer who is affiliated with the same institution as any of the authors and we ask reviewers to declare any potential conflicts of interest, such as personal ties to an organization with a vested inter-est in the topic of the manuscript. Editorial Decisions We judge manuscripts on the interest and importance of the topic, the intellectual and scientific strength, the clarity of the presenta-tion, and relevance to our readers. We also consider the strength of the paper compared with other papers under review and the number of accepted and previously published papers in the paper’s category. Authors of original research and review articles should take pains to describe exactly how their findings add to the existing literature.



The Editorial Office is committed to providing prompt process-ing times and to communicating timely decisions to authors. While the Editorial Office makes every effort to notify authors and keep them informed of any delays, most authors can expect a first deci-sion on their manuscript in approximately 4 to 6 weeks.

We communicate editorial decisions on acceptance or rejection only to the corresponding author. Almost all papers that we accept require some editorial revision before publication.

Accepted Papers Page proofs (PDFs) are e-mailed to the corresponding author before publication. Authors can expect to receive proofs approxi-mately 3 to 4 weeks before the scheduled issue date. All proofs must be returned to the Editorial Office within 48 hours.

References 1. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals: writing and editing for biomedical publication. [Updated April 2010.]http://www.icmje.org/urm_full.pdf. Accessed October 5, 2012.2. Iverson C, ed. Ethical and legal considerations. In: American Medical Association Manual of Style. 10th ed. New York, NY: Oxford University Press; 2007:125-300.

Editorial Offices are located at:The American Journal of Hematology/Oncology Office Center at Princeton Meadows, Bldg 400 Plainsboro, New Jersey 08536E-mail: [email protected]

Documents

F L A T H E O F ColoreCtal CanCer Hematology ajho · ColoreCtal CanCer Adjuvant Chemotherapy in Older Adults With Colon Cancer Grant R. Williams, MD, and Hanna K. Sanoff, MD, MPH